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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 - 1210465 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- fj )1 _ I Inspection Type(Fill one) <br /> Site Suffix: 1 "1 ® Routine Q Re-inspection Q Referral 0 Observation <br /> Local // _� L If Referral,choose referral type(Fill one) <br /> Identifier: S(nC��d iJ� �� W u n)� 0 CHP 0 CalRecycle Q Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> \\I So <br /> /� Inspection Date <br /> L��'i�1 S c�Q C U1 �(533� <br /> Time In Time Out <br /> Business Rep Title 0 Al (� AM <br /> ® PM 1 0 PM <br /> 5l j 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 /> ' 16 ® Active 0 Passenger • Generator 0 Outdoor <br /> O 0 Closed Q Altered 0/A <br /> GPS Latitude 0 Hauler O Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - 0 Planned B OTR O End-Use 0 Container <br /> Business Type(Fill all that apply) 1: 'f <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture O Shredder ® Other aj4 j;b�, i(� A 6'r,4-'r <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Notice Of Violation 0 Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> a <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> LU <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ®In Compliance-No Violations o <br /> Q O Other:§ <br /> � � �LL I' p <br /> Comments �A�1 lu, �,5�f'c. 1v 111S( CAU 11 �,( V�� S !���t� (.t(10\\ <br /> - ,N0y;LAO�V)v of c,L fc_y�5Clqns,rn <br /> Inspection Form Included: Q�-���✓�I 6 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Ins tor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A L 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Col:LEJV <br />