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Waste Tire Su, Bey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle 11 - 1196294 <br /> CalRecycle 181(Rev.10/10) <br /> (Cal Survey Form - Page 1 <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� © � � � _ 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: 50.,E \� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> u, � " <br /> rc�c- Sccv�C-� I v�G. ?� G, - O ��'� -'Vv <br /> Physical ddress <br /> 253$5 S� ��� �,�• <br /> CA Inspection Date <br /> `Tri-`� "� ��� Time In Time Out <br /> Business Rep \ - Title 2 * AM S *AM <br /> Q PM Q PM <br /> �� h� �l �' J S <br /> ll <br /> VN Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 60 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 4D Active Q Passenger 0 Generator Q Outdoor <br /> O <br /> GPS Latitude Q Closed Q Altered <br /> Q Hauler 9 Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned 0 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 /> 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 ! 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 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 /> PRC§42956-Registration/Decal in Vehicle <br /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / FTI <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 or EX7) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments AryCe, Nwe\R C� &> \� <br /> o-(z o� wC�MS <br /> Inspection Form Included: Q 7� <br /> Comments Included: - - - -- 1Z ` 95 S'� <br /> me Is ig_nature - Phone Number Inspector's Signature_ Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E�XjAjMjPjLjEj 11 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © 0 <br />