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M Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 -1176399 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A—Survey- <br /> -----------------—-- -- <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 1 3 1 Q v lJ J 41 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SGl(1 Jb Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address C S Qi V <br /> // Inspection Date "7 1 <br /> �<SX5 Time In Time Out llI <br /> Business Rep Title I 5 O AM � 5 O AM <br /> PM ®PM <br /> Operational Status Tire Type Business Role Storage Type <br /> ` (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 1 <br /> Active ® Passenger ® Generator � Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber Q Service Station Q Hauler Q Agriculture Q Shredder ® Other O1e�,( T[WI <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 Q 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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <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 /> w <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> U rS ' N <br /> _ <br /> No viola. rips cis a ( ane-e-(n <br /> Inspection Form Included: Q <br /> _ -`-�-- - - 931-06 3 X - <br /> Comments Included: ®f <br /> I Business Rep's Signature Phone Number Inspec is Signature Phone Number <br /> --—` <br /> _4 <br /> 1111 62081 <br /> INSTRUCTIONS ON BACK lCorrect:* Incorrect: �X V1 X A M L 1 2 3 <br /> ■■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy. © <br />