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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of <br /> CalRecycle CalRecyclelifornia 181(Rev.10/10) 11 — 1242160 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Fora - Page 1 <br /> Part A-Survey __ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I /-V � � � � Inspection Type(Fill one) <br /> Site Suffix: '0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SCI.Y\ TG r,n v\� v� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name `�`� Inspected By Inspector <br /> >� dre� xes5 , Q _ o ` MAS <br /> s <br /> Phy c I Ad <br /> 55 - <br /> Inspection Date 7 / (z, / <br /> Time In Time Out <br /> Business Rep Title 1 \ *AM \ *AM <br /> 5,3c-rt S O PM l 1 d 0 PM <br /> Bca�c� Skean—I.b 2 V. :n`aM�1�an;c�� <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 /> Q Active QPa% er Q Generator Q Outdoor <br /> Latitude O 0 Closed Q Altegggred QI� Q I A) <br /> GPS r <br /> O Q Inactive Q 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 Trucking Fleet 0 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 <br /> Q Service Station Q Hauler Q Agriculture Q 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 /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 <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 EX7) <br /> a <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 0 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:§ z <br /> Comments ` <br /> ov` lov.\S <br /> ce cL ;� 4a�w_ -7`611.2. ys Z`nes S IS ro Io-SRS <br /> Isca�;c�r �.�v►ntn+�,n� �„�s "�D � ca�5ec�.. 4.S �:c�s o��cv ans��e <br /> inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep Signure Phone Number Inspec or's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:4j Incorrect: E X M P A L E 111213 62081 <br /> . White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />