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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 I1 1226398 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Fart A - Survey BLUE OR BLACK INK-PEN <br /> Business <br /> NKPEN- <br /> Business Profile Inspection Details <br /> TPID- ' / ` 5 _ I Inspection Type(Fill one) <br /> Site Suffix: 19 ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> � L <br /> Identifier: (11n Jo Z, V l n OA Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 7 l- S. �i c �nSPUr���l v� <br /> Physical Address GS�UV <br /> Ic l D.0 5- yaflrnr <br /> Inspection Date <br /> r✓R 95 <br /> Time In Time Out <br /> Business Rep Title 0 AM0 AM <br /> 3 <br /> PM ® PM <br /> ® <br /> ��c� QpQrU,�i�n5 mgC. <br /> 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 D Q Closed Q Altered PJ Q Hauler Q Indoor/14 <br /> o Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 9 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 ? l <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other ` f al lel yp�j(� <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 / M / Ffl <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <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 0 <br /> 0 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <br /> Lu <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:§ L L Ll- <br /> Comments 1Lb a,r\0 _ uj(�S}c� —f)t e. 1/l S i O/N rXA3-sv , r)11 M.nJ �f 1"10 'F ( 11 <br /> No n 1 wc-c45, 0�" rn-n-c'm, <br /> Inspection Form Included: Q <br /> Comments Included: ® <br /> Business Rep's Signature Phone Number Insp or's Signature_ Phone Number <br /> � <br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect: X N) E X AV 1 2 3 62081 <br /> eWhite Copy:CalRecycle Yellow Copy Operator Pink py: �� <br />