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Waste Tire Survey & Inspection Report Inspection Report Number <br /> Cal Rec cle State of California _ <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 1 1210292 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A BLUE OR BLACK INK PEN <br /> -Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: S "j 0 C> l 'c 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SQA � � L©'.N\,hj 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address �J - l 10 .41 , pt4aDt-� <br /> Inspection Date ( J <br /> Time In Time Out <br /> Business Rep Title & AM AM <br /> ( 0j Q PM <br /> QPM <br /> _Sc�aK ( Ill �Lti�r <br /> -- --- -- --- Operational Status Tire type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> //�-��� U <br /> ® Active ® Passenger Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 10 Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer ®Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ® 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 � Extension <br /> O O <br /> 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 / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) 14. <br /> 0 Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years I <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> W <br /> W <br /> 0 O 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 ®In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments <br /> Inspection Form Included: <br /> Comments Included: <br /> sin s Rep's Signature Phone Number n ector_. Si atu Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: J.EJXJA M E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy. © ■ <br />