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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecle State of California <br /> cycle CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 1242373 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Survey <br /> A-Survey BLUE OR BLACK INK PEN <br /> iess Profile Inspection Details <br /> TPID- In <br /> spection® � Inspection Type(Fill one) <br /> -7 � ® � � � <br /> Site Suffix: ! Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5aY, a ,�Y\ Covy\� O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name C51nc'�rti� Inspected By Inspector <br /> �Q��,,%r Ca�,��y ������acl�s e��l n _ 1 0 1 MMT Q <br /> Physical Addre s 39 <br /> 52 0lore ZJ2 <br /> Inspection Date 02- <br /> e_111 Inspection <br /> 0\ 95361 Time In Time Out II <br /> Business Rep Title /� O AM AM <br /> 1 d 5 0 PM , 2 ® GPM <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 /> 9 e (ice- Q Active Q Paa�sJsgrlger Q AG,ne,ntor 0 Outdoor <br /> O v Closed Q Altered Jve aN <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Vew Tire Dealer Q Auto Repair Q Trucking Fleet 0 Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> U Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder S Other CN-,P- <br /> Part <br /> NSPart 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 /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> O 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> a <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O Q 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 ®In Compliance-No Violations o <br /> O O Other:§ <br /> Comments ,` tN <br /> _ <br /> o6a,rf. kav 55c, %J0\<<- v\Tc, orOear \Z,y <br /> � c c.. <br /> inspection Form Included: Q V <br /> Comments Included: Q a�\ ~���`� <br /> Business Rep's Signature Phone Number AInspectis Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct aIncorrect: X E X A M P L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />