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Waste Tirefte 8 Inspection Re Inspection Report Number <br /> CalRecycle State of California y — <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 1 1 1178017 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR SLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 (� Inspection Type(Fill one) <br /> Site Suffix: o 1 u q I& Routine Q Re-inspection Q Referral Q Observation <br /> Local / L If Referral,choose referral type(Fill one) <br /> Identifier: SAA �Oa, 1A)l 1 l.0 un` Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> I Inspected By Inspector <br /> C ,s� 5 G��c4 Ti f, a - t o o <br /> Physica Addres 3 l Lb <br /> I fl �� Inspection Date / l 5 <br /> C �� 95Z�S <br /> Time In Time Out <br /> Business Rep Title S AM AM <br /> Q PM V Q PM <br /> Cu Scv� aIS 0^4 G nv- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> 3 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � � G! <br /> ® Active • Passenger 0 Generator I* Outdoor <br /> O Q Closed Q Altered <br /> �aP� Latitude Q Hauler Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> QUsed 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 <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 /> PRC§42956-Registration/Decal in Vehicle <br /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / Ffl / <br /> m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <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 m <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 /> z <br /> Comments . :1eAsJ�' t v ns . N <br /> � O \OWIM\ - - <br /> ,JNc) J i O IGti i Oa �Jf_(a&_Vf cant <br /> tet� <br /> Inspection Form Included: Q �C q�&341nspe <br /> Comments Included: "Y -"— I - <br /> Business Rep's Signature Phone Number s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: � � � EXAM P L11 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop : ® ■ <br />