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Waste Tire Sui vey & Inspection Repon Inspection Report Number <br /> State of <br /> CalRecycle CalRecyclelifornia 181(Rev.10/10) �p I1 - 1196714 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form 1 n = Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 b f 39 5 -7 - O Inspection Type(Fill one) <br /> Site Suffix: O Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 1�(kr J 6r%0 6'6(\ C,.C)�.tyXy Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> X0_0\ "Co �\q -� ct - \ 0 L MAT T <br /> Physical Address <br /> tq o N1A0 C�� c C•c cle <br /> SVo 6e koVn <br /> CA\ 95212 Inspection Date <br /> Time In Time Out <br /> Business Rep Title ' 10 AM O Q AM�� <br /> A� I J Q PM t PM <br /> — - — -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count hol /PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' • Active 0 Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> �PS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use 0 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 40 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 I 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 /> 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 <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 /> Uj <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 9 _ kxvl�e_ V�>C''-_SNP_ '' �� ``S;..P . ��V�, `_ o)6& CM T &LC��. <br /> AN <br /> to. �owS <br /> Inspection Form Included: Q (� <br /> . Z b <br /> ��Comments Included: Business Rep's Signature Phone Numer Inspec is Signature Phone Number <br /> • X r-�( 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: / E X A M P L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />