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Waste Tire Survey & Inspection Repor4. Inspection Report Number <br /> CalRecycle State of California I 1 - 1176836 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A - Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) BMP <br /> Site Suffix: (,) 1 0 Routine Q Re-inspection Q Referral Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 1C_.1C_A Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> y skD0�4�-� � ��� - I v ) Ai Zmlo <br /> Ph sical Address <br /> ,:2Uc-3- � - t�c�,mm,e r Z�1, . <br /> . ,^ q Inspection Date Q / ,r-� L/ � l <br /> S V0L� `�._C ` /'� `sac) Time In Time Out <br /> Business Rep Title AM AM <br /> Pm <br /> /let <br /> r 1 • 0 Q PM <br /> n u Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 1 <br /> � l ® Active ® Passenger ® Generator Q Outdoor <br /> PS Latitude Q Closed Q Altered Q Hauler � Indoor <br /> G <br /> � Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer ® Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body ® Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m m N <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q (Required for NOV or EX7 <br /> N <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years F <br /> Q Q Q Referred/CalRecycle Enforcement <br /> 14 CCR§18460.2 Manifest System Requirements for Registered Waste Tire Haulers 2 <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations o <br /> Q Q Other:§ _ <br /> Comments <br /> m <br /> Inspection Form Included: <br /> Comments Included: _ <br /> Busine s Rep's Signature Phone Number do p t s ig ature Phone Num <br /> _ ber <br /> �,( 62081 <br /> INSTRUCTIONS ON BACK Correct:6 Incorrect: � N E A 1 2 3 ■ <br /> White Copy:CalRecycle Yellow Copy:Operator Pink C y:L <br /> ■ <br />