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Waste Tire Sup vey & Inspection Report inspection Report Number <br /> Cal Rec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey FOrmA - Page 1 I1 1210294 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: I '� C O Cl - 0 a Routine Q Re-inspection Q Referral Q Observation <br /> Local \ II � If Referral,choose referral type(Fill one) <br /> Identifier: Sap JscxmCt l/IV` '6(D WL�"'L� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name rr/ Inspected By Inspector <br /> C2z, —1-b--e_s, l D <br /> Physical Address <br /> ✓ICA s Pct . �I <br /> Inspection Date /lj CA q�O <br /> Time In Time Out <br /> Business Resp+ Title ® AM O AM <br /> IV�Z� (.i,tJ D✓\ (..G�Mpi►�" I l J 0 0 PM L Z_ � © ®PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) -7 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 �[ 0 0 Active Q Passenger 0 Generator ® 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 • 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 /> 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 (a Other � � "TI�y, 3�i✓1/�Z <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 Q Extension <br /> Q Q 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 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date / F1fl3 <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 E?CT) N <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 /> LU <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance No Violations o <br /> Q Q Other:§ <br /> - - - - z <br /> Comments ` <br /> Inspection Form Included: Q / I / <br /> Comments Included: <br /> Business Rep's Signature PhoneAumber s t s ignature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X- JAIAIPILIEI 11 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />