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Waste Tire Sui ,rey & Inspection Report _inspection Report Number <br /> CalRec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1242103 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 6 ^M � _ 0 1 Inspection Type(Fill one) <br /> Site Suffix: `Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: JQh V;,4\ CoV Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 2) q - l O 1 M �'�' v <br /> Physical Address <br /> 2 2 0 W. W G SN,:��rov�, <;X. <br /> Inspection Date O Q / Z O / I LA <br /> 7 `�Oh $Z0� Time In p Time Out <br /> Business Rep Title 1 O AM O AM <br /> � O PM O 40 PM <br /> rvw` l <br /> Deer'-s 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 /> • Active 0 Passenger ! Generator • Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o I Q Inactive 0 Truck <br /> Longitude - Q Planned 0 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet • Gcvemment Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q C Rection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q S+redder 0 Other go V L1 ski`7, - <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 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 EXE <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years u) <br /> 0 <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 In Compliance-No Violations o <br /> Q Q Other:§ `' <br /> Comments n �=.cL �v�sP"-o1n �hv�e br �t�.:S c��. aAAAAR <br /> Q <br /> Inspection Form Included: Q ��_,1/ (�j�?20•�l <br /> Comments Included: ' '`� —a � <br />