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■ Waste Tire St,. ,iey & Inspection Report Inspection Report Number <br /> State of California <br /> Cal RecycleI 1 - 1210434 <br /> CalRecycle 181(Rev.10/10) <br /> (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Sart A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID_ - O Inspection Type(Fill one) <br /> Site Suffix: '0 Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: Sam J Q r, a L�r, (( u(�' Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Addr�SsC � � - <br /> 1 1 CSCOTJfD <br /> lW% S- <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep (� Title S %AM O AM <br /> JUf S , m 0 PM ` O ® PM <br /> - <br /> ,� Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) Ca 3 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> % Active Q Passenger ® Generator 16 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <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 Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> --& sedffireDr <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® 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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> (Required for NOV or EXE <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days N <br /> r <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 /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> Q ® 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> 1 �LComments}ro �J1��+5�� \r`� Sf c)-..4 - N <br /> nspection Form Included: Q - - <br /> Comments Included: l ture Phone Number-91r.7-6 97v (� <br /> Business naInspe is Signature . one Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: I E I X I A MI P I I E 1 1112131 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ■ <br />