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Waste Tire S#ey & Inspection Report Inspection Report Number <br /> CalRec cle State of California <br /> Y calRecycle181(Rev.10/10, 11 Form �, Mage 1 11 1177648 <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: 1 - (� LC ( ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: v` ""k '/'M , Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name r Inspected By Inspector <br /> Physical Address J l f 4-mftw_� <br /> Inspection Date <br /> Time In J Time Out <br /> Business Rep Title �yy__ AM 0 AM <br /> � <br /> jr� TA `CtU�'1, � O PM ( Z7 QPM <br /> �"� �2� ✓ 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 /> Q Active QPa�sg(engAer Q GenJe,rator Q O�utddoor <br /> GPS Latitude ® Closed Q Altered 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 /> 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 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 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 /> 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 E)(7) 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 /> 2 <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 1 -- ► &Dl! neo - <br /> P ty�rt�G� �I)P 1 1T •1' <br /> cn— r >R A]Q U.J)jCA-hj)n S C� `�G� S p�-�.tM��rnS alb S <br /> 121 <br /> S . i'J'l G t` i Cl4 y f <br /> Inspection Form Included: Q 2oq_�z 3-7167 <br /> Comments Included: Q -- <br /> Hess Rep's ignature Phone Number n r gn ure Phone Number <br /> 62081 <br /> INSTRUCTIONS BACK Correct:0 Incorrect: X E 1 2 3 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />