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Waste Tire Su, ✓ey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1210320 <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- 1 49 n _ I Inspection Type(Fill one) <br /> Site Suffix: L 4P Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHIP Q Educational Visit Q OtherI _n � <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> I ^ Inspection Date <br /> �'` 'n`��°` C ���"3 Time In v Time Out <br /> Business Rep Title 0 AM\ 1 � � O 0 AM <br /> \ QPM QPM <br /> 10.Y� SZ C�d.Q,CSb a� �" 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 /> 0 Active 0 Passenger ®Generator 0 Outdoor <br /> 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 /> 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 0 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 HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires - - Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / M / m <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 EX7) <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 /> 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 <br /> go rP �v�.S P�2.0 t'L— C v�p aa� v� • <br /> Wa-S rnoke <br /> ?er. <br /> Inspection Form Included: Q a y <br /> Comments Included: ® C61? C 2� �� ` <br /> Bs usinesRep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X IEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />