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M Waste Tire Survey & Inspection Repon Inspection Report Number ■ <br /> CalRec cle State of California <br /> Y CalRecycle 181(Rev.10/10) ®�� o �a�� 11 - 1177689 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 13 Q $ 5 1 9 O L ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �v� If Referral,choose referral type(Fill one) <br /> Identifier: �� ��-� ��. Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> [' A-LA-Vt O lAmyn h�,l <br /> Physical Address <br /> e,_ <br /> 3,►o3 IE , <br /> a Inspection Date <br /> ��� G� Time In Time Out <br /> Business Rep Title O AM O AM <br /> i • 3 QQ PM C ! O ® PM <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 /> p2 D ® Active ® Passenger a Generator ®Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> V New Tire Dealer ® Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 EXE N <br /> a <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 /> 2 <br /> W <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:§ __ z <br /> Comments <br /> n <br /> Inspection Form Included: Q <br /> Comments Included: 6 r _y -� 7 <br /> ep's Sig ure Pho 1e Number ( s or' S' natu Phone Number <br /> INSTRUCTIONS ON BACK Correct: 62081 Incorrect: E X A E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cy: ® ■ <br />