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■ Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Cal Rec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1226592 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Surve)t -- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- LA <br /> I � - O l Inspection Type(Fill one) <br /> Site Suffix: I & Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalC If Referral,choose referral type(Fill one) <br /> Identifier: Jan J O GLC(ui r) C 17L1(�� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name J <br /> QI L 1 � Inspected By Inspector <br /> e <br /> Physical Address 3 I l <br /> 0 <br /> $330 <br /> Inspection Date bTime In Time Out LLL <br /> Business Rep Title 1 1J V *AM 'l Q AM� QPM � � � V � PM <br /> T L ��SIJ� Su 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 /> 6 0 Active • Passenger ® Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) n <br /> u) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> Lu <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> 0 0 Other:§ ] <br /> Comments tlr\e� Y, <br /> No '1 i �a I U� -�)sil 3 of_�1 an - <br /> Inspection Form Included: 0 <br /> Comments Included: •- -- — - Gr�s�ignatu5�kBu nes Rep's Signature Phone Number Inspec Phone NumberINSTRUCTIONS ON BACK Correct: Incorrect: EXA1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L © ■ <br />