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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1177853 <br /> CalRecycle 181(Rev.10/10) <br /> (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 nInspection Type(Fill one) <br /> V <br /> Site Suffix: 1 (J Routine Q Re-inspection Q Referral Q Observation <br /> Local }- If Referral,choose referral type(Fill one) <br /> Identifier: sun _Joni�1rn �('lJ(�1� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Vofa �'x _ <br /> Physical Address G 1 , <br /> J�kOLb^ Inspection Date 1 / 0 <br /> '1 C� ��ZTime In Time Out <br /> Business Rep Title I ( ® AM I ( IP AM <br /> r i <br /> JQPM 1 � V QPM <br /> ens or - 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 /> Q Active Q Passenger It Generator Q Outdoor <br /> D Q Closed Q Altered NA <br /> GPS Latitude Q Hauler Q Indoor <br /> O 0 Inactive ® Truck <br /> Longitude - Q Planned Q OTR 0 End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair (9 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 <br /> Q Service Station Q Hauler Q Agriculture Q 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 /> Q Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / M / m N <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators is In Compliance-No Violations o <br /> Q Q1 Other:§ <br /> Comments Q D \ na 1 A)(AVfc_ n5" AD 97N& l)ll7) ll � � Ik nu))r) <br /> U,V i (A I C(AL o (Qr)Ccr f1% <br /> Inspection Form Included: <br /> Comments Included: <br /> Busl Rep's Signature Phone Number Ins ctor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ACK Correct: Incorrect: g E X A M L 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co <br />