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Whste Tire Su. ✓ey & Inspection Report inspection Report NumberState of California <br /> ■ <br /> CalRecycle CalRecycle181(Rev.10/10) Surve Form - Page 1 I1 - 1210406 <br /> Dept of Resources Recycling and Recovery(CalRecycle) Survey g <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 5 p. - O Inspection Type(Fill one) <br /> Site Suffix: �(1 If Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Su n J0( L) ) ,' Cot"n� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> l Inspected By Inspector <br /> CNS '_.� n+cltlus, - d <br /> Physical Address 3 �((►� T, 1 W ``'�1 b <br /> �Vlr��� Inspection Date <br /> S o CA 1SZo� I t <br /> Time In Time Out <br /> Business Rep Title O AM C� O AM <br /> M a ' f D 'g % PM 3 � J a PM <br /> ` Ukd11J4- 'D�eA 0 sm121bCu5 �' e .'A <br /> Operational Status Tire Type Business Role Storage Type <br /> 1 <br /> Tire Count (Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> l <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned a OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) 7fUrk1 <br /> 0 New Tire Dealer 0 Auto Repair 0 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 4P Other (Y1unl(�u 4uJ'- <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 /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / 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 EXE n <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> w <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 <br /> In Compliance-No Violations o <br /> 0 1 0 1 Other:§ <br /> Comments TP�� <br /> ctir�Lk <br /> Inspection Form Included: d JI;V( �d `7-13 - 1-7 ` - i e <br /> Comments Included: ® <br /> Business Rep's Signature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 7X*V71EJXJAJ 1112131 <br /> 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co y.L ® ■ <br />