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Waste Tire Su. ,iey & Inspection Report inspection Report Number <br /> CalRec cle State of California <br /> Y CalRecycle 181(Rev.10110) Survey Form - Page 1 1 1178018 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I Inspection Type(Fill one) <br /> Site Suffix: ' 3 3 ` o ! 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier. S«ne�QUJ n (Au^ `� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 4 Inspected By Inspector <br /> rrko Lu3 .Lm-. <br /> Physical Address l I <br /> \ Iq() SQA , IIIJJJ <br /> (�'� Inspection Date <br /> (� <br /> ✓`' ' 1 C� � CA � ��� Time In VJ Time Out <br /> Business Rep <br /> Title I O AM l O AM <br /> S JL coc rz1\ lerICc1 T50 PM 04111 PM <br /> Operational Status Titre Type Business Role Storage Type <br /> Tire Count (Whole/PTE) i I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' l ` 0 Active 0 Passenger 0 Generator ® Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> O 0 Inactive ® Truck <br /> Longitude — 0 End-Use Container <br /> 0 Planned 0 OTR <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair Is 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 Notice Of Violation 0 Extension <br /> 0 0 <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 /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date N <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years a <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <br /> Lu <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 I*In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments 11 J ( N <br /> Inspection Form Included: 0 <br /> Comments Included: • <br /> us Hess Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: E X AMP L 2 2 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink C y:L ® ■ <br />