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Waste Tire Sup vey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle I 1 - 1196689 <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- I I `1 I If <br /> nspection Type(Fill one) <br /> Site Suffix: Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sckh J00_ 4 7 V;� Cu�k` , Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name � Inspected By Inspector <br /> CTS Cce �,� `�'�rZ, <br /> Physical Address <br /> �Wmy qC <br /> C�V C�>2\ ` Inspection Date ` 2 <br /> S Time In Time Out ` <br /> Business Rep Title ` C O AM O AM <br /> 1 O J ® PM I * 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 /> i Active 40 Passenger e Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned • OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 M06t .9— A--,,ft SQCV-Ke— <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 /> 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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> r <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators &In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments S� \ - ---�\_ � ` ' <br /> '�o•���.rQ. Vero- h�����r�.SP�c�o c�s�VI� <br /> rcG•S �o <br /> -� <br /> CM L � <br /> �Jo �S3: c ee\ O c �-S_ & coy env` <br /> Inspection Form Included: .t <br /> Comments Included: — --- ---�®r,Bus' ess Rep's Si ure Phone Number InspSignature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: jjjj � jjjE X A M P L E 1111 <br /> 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />