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Waste Tire Sup vey & Inspection Reporn Inspection Report Number <br /> CalRecycle State of cle181(R 11 _ 11- 76364 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 1 L <br /> Dept.of Resources Recycling and Recovery(CalRecycle) _ BLUE OR BLACK INK PEN <br /> Part A-Survey - <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: , Q 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local /, If Referral,choose referral type(Fill one) <br /> Identifier: SCA_1V, �('����` �f1 Y t (.(J(/Y�/ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address irrzcmh� ,( ' <br /> Sow CAD rx,�CT-I oo -01 t� . — <br /> Inspection Date <br /> svcx_l -+vim CA a.-a 05 <br /> Time In Time Out <br /> Business Rep Title 0 AM AM <br /> l U J o OPM 3 S OPM <br /> YK 1O' OpBusiness Role <br /> erational Status Tire Type Storage Type <br /> 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) 7 "-7 ..7 <br /> ® Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR ®'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 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 <br /> M / M / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EX7 <br /> Q Q N <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> a <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 /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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:§ - z <br /> 4 <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: <br /> usinessSiSignature Phone Number *Co - <br /> Phone Number <br /> - • � �� 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: �/ I1 2 3 ■ <br /> ® White Copy:CalRecycle Yellow Copy:Operator <br />