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Waste Tire Sui Bey & Inspection Repor%. Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1226626 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK P E N <br /> Part A-Survey — --- - — - -- <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: L-, C ® Routine Q Re-inspection Q Referral Q Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: Sr,/-1 �1� �f:�il�� �c� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> I1��� a� 2 <br /> I Inspection Date AA /j, <br /> C(-5,190 _f <br /> ���0 CA Time In Time Out <br /> ® AM O AM <br /> Title <br /> Business Rep / b d O PM 3 V 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> . Active ® Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GP$ Latitude ;0 Hauler 0 Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR 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 <br /> Q Service Station ® Hauler Q Agriculture Q Shredder Other 0�ll e �Uyyl>✓ k;1ke_[ Ae& ,�6 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date� flr,- / N <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§ (Required for NOV or EXT) <br /> 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days a <br /> ® Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q Q Referred/CalRec cle Enforcement <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers y � <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 Q In Compliance-No Violations o <br /> Q Q Other:§ - <br /> 4 <br /> Comments <br /> ed� v - <br /> Inspection Form Included: - <br /> 7 <br /> Comments Included: ® Busine e o umber Insp c r S' n ure Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BAC orrect: Incorre t: � W E X A M P E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />