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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1244939 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: I 3 r7 a U © 46 Routine 0 Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: -in_�Sewy Lf t r1 Co lit�l O CHP 0 CalRecycle Q Complaint Q Educational Visit Q Other <br /> 44 <br /> Business or Facility Name Inspected By Inspector <br /> Sio t✓1 L+u-,\ Ls(V)'S 3 <br /> Physical Address <br /> &)D-0 'S <br /> Inspection Date � O � I <br /> Saco ckAro GA IN-& I <br /> Time In Time Out <br /> Business Rep Title 0 AM I 0 AM <br /> 1.t1 rn�s'�tl�LhlS Ctrs 1Z+1Q 1' a 3 PM 3 L #PM <br /> l j Ax V 1l G�, n'JILVG` �t, Ic�R^TifLGI' <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1 (_ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> v * Active ® Passenger 0 Generator Outdoor <br /> O Q Closed Q Altered l <br /> GPS Latitude Q Hauler O Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned OTR O End-Use O Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 0 Government Q Retreader 0 Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Othert-�'�J �� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O O Q Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> OO 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date MCl / <br /> m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> W <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> O O Other:§ ],, ` <br /> Comments �yl-t��Q� W vlrskr 1 \'f C_ I n 51�Za/� <br /> D <br /> Inspection Form Included: Q <br /> 4L <br /> Comments Included: ® <br /> Business Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P L E I I 1 2131 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: <br />