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Waste Tire Sur vey & Inspection Report 'Inspection Report NumberState of <br /> ■ <br /> CalRecycle CalRecycle1ifornia 181(Rev.10/10) — <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Survey Form Page 1 I1 1242329 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Cl - I Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local y If Referral,choose referral type(Fill one) <br /> Identifier: Sa{t�vwp �; CU1An11� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I Inspected By Inspector <br /> S1Q_"CA. C.�kcm{ LA q _ <br /> Physical Address //�3 1 V l GS t0TT0 <br /> .i( o <br /> 4J L J of� (A 9 S l 6 Inspection Date <br /> 1 Time In Time Out <br /> Business Rep Title r 5 S O AM O AM <br /> loll' SV�cNC�' Pf� S Gni • PM J S 0 PM <br /> �CQT 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 /> ® Active Q Passenger Generator Q Outdoor <br /> GPS Latitude O Q Closed Q Altered NSI <br /> Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned 0 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q 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 <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 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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXTJ n <br /> Q 0 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 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 /> Comments ao4i6�y � <br /> G ,sc' Ing i U') GjA1AL- U--)4l,�r 113 o (J6 Ann c4 <br /> WAS f0 c = <br /> JeR, C(Nnms t.S Fo j* - <br /> Inspection Form Included: Q <br /> Comments Included:® �6-1 �` / � �? �V o_✓7�� <br /> Business Re s Signature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X JEX A M P 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L <br />