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Waste Tire SG. Bey & Inspection Report Inspection Report Number ■ <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1210356 <br /> Dept.of Resources Recycling and Recovery(calRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ,A <br /> �A O Inspection Type(Fill one) <br /> Site Suffix: 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: SSV\ C�C��U �C�VV__'C�/ _ 0 CHP 0 CalRecycle0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name / Inspected By Inspector <br /> rM <br /> CC-0 ��y-e- v L CT 1Z x 1 <br /> Physical Addrel �� , 3 I d 1 'T q\,) <br /> 7 26 S . A'%5�l wy q 9 <br /> l Inspection Date / O / 3 <br /> 5 vc.86�01/\ cA <br /> Time In Time Out <br /> Business Rep Title 16 AM 7 Z O AM <br /> Kev_ QPM � L J � ®PM <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 /> L 0 Active 0 Passenger s Generator Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler !Indoor <br /> O 0 Inactive ®Truck <br /> Longitude — 0 Planned 0 OTR • End-Use Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government ® 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 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 /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / Ffl / <br /> 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 EJC7) N <br /> 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> LU <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators join Compliance-No Violations o <br /> 0 1 0 1 Other:§ <br /> Comments 2 Q0%V*%t 1 .-w!��9_ V1,'f`P__ Ly1`4P �n in 1n 2 o yX ' 3115 <br /> Qcey�o�s /�c-e� o� C��c2C'h �na5 �j�+cln orrcC <br /> co M e-VAS <br /> Inspection Form Included: 0 I 4/ / `t1 Cs/ <br /> Comments Included: I �J 1! l <br /> Business Rep's Signature Phone Number Ins�'s Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: E I X I A IMIP I L I E 1 1 62081 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />