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Waste Tik,. Sur vey & Inspection Ret.,)rt nspection Report Number . <br /> cal Recycle State of California _ 11 - 1226502 <br /> CalRecycle 181(Rev.10/10) Survey Form Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycie) <br /> BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: ` L4 I Li I 93 C) I O Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> /�� <br /> Identifier: S�.lv1 � � Y 4 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 3 1 �. �� A2i rn6Ulc,.- <br /> - <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title AM 0,AM <br /> 10 <br /> O PM 1 C) C 0 PM <br /> iy f 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 /> 3 ® Active ® Passenger a Generator ® Outdoor <br /> o Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> o Q Inactive Q Truck <br /> Longitude — Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type(Fill all that apply) <br /> New Tire Dealer i 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 I A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement s <br /> ui <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance No Violations o <br /> Q 1 Q Other:§ <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: ® -� <br /> Busine ns WS* n <br /> 's Signature Phone Number IPhone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � W E X A L 1 2 3 <br /> MWhite Copy:CalRecycle Yellow Copy:Operator Pink Cop L ® ■ <br />