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Waste Tire Survey & Mspection Report Inspection Report Number ■ <br /> CalRecycle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Fora gage 1 1 1242324 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey___ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- - O I Inspection Type(Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Localc �` If Referral,choose referral type(Fill one) <br /> Identifier: San UdLo 1, un f�I 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1 J Inspected By Inspector <br /> Physical Address C-scU7To <br /> r A q S-Lo Inspection Date / <br /> 1 Time In Time Out <br /> Business Rep Title O AM n 0 AM <br /> e PM d� ' 0 PM <br /> Sa,,UP'N . C-seosi+o of iu r�qqr <br /> - -- — -J— - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (V1/hole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> a Active 0 Passenger 0 Generator ® Outdoor <br /> GPS Latitude 0 Closed 0 Altered 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer ® Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 <br /> O 0 § - - — Notice Of Violation 0 Extension <br /> PRC 42951 Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> a <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs.for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> Uj <br /> W <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance- No Violations <br /> 0 0 Other:§ - <br /> Comments Q,04A' W1 'e. f¢� IrlS�e(.Til11l J'Ora' Vj% '6()3 3 ZAP 01 � �� <br /> N O V1 dla ;vill S a f cj,fccAS eT- COMP-M, <br /> Inspection Form Included: 0 <br /> Comments Included: ® 01 <br /> 4ftsiftp's <br /> re P e Number Insp or's Signature Phone NumINSTRUCTIONS Oj Incorrect: E X A M P L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co y:L <br />