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Oa Waste Tire Still vey Coy Mspsct� uln Report , Inspection Report Number <br /> Cal Recycle State of California <br /> CalRecycle 181(Rev.1 0/10)(Cal Suirvey Form _ page � I1 1242383 <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: G �, l C - Q Q Routine ® Re-inspection Q Referral Q Observation <br /> Local C If Referral,choose referral type(Fill one) <br /> Identifier: SCS V\ JUft� ��-1 C"� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name In-sppected By Inspector <br /> Physical Address - ` 0 t Ah v tSU-1, <br /> (/lInspection Date � / ,py 5 / j Ci <br /> C��� �CC� C� �s Time In Time Out l Z <br /> Business Rep Titlee O AM O AM <br /> ' 6 5 *PM � pS � a PM <br /> L.kWan_� w ,- Own e.r— <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> X3 0 Active • Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> ��� Latitude 41 Hauler 0 Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR End-Use ® Container <br /> Business Type(Fill all that apply) <br /> 110 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q 0 PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> r <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations o <br /> Q Q Other:§ <br /> - a <br /> Comments <br /> Inspection Form Included: Q � ` 1 <br /> Comments Included: ! <br /> Business Rep's SignatLke Phone Number 41pehito4,19ti�gTat—u re Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAM E 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co y L <br />