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Oa Waste Tire Survey& Inspection Report0lnspection Report Number <br /> CalRecycle of CaalRecycle1ifornia 181(Rev.10/10) I1 - 1242362 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Su rvey Form - Page 1 <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- 1 1, -3 � � � � o Q � Q <br /> Inspection Type(Fill one) <br /> Site Suffix: `� Routine Re-insp Q Q ection Referral Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � V CGS n / - Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name \ Inspected By Inspector <br /> V2AAddretss �'CJ�1r�Se0` '�1C7`� cove• —2->Phy <br /> 661.0 W. o\�>'KV0-W. <br /> Inspection Date <br /> Tcc�c�r C gS3ny <br /> Time In Time Out <br /> Business Rep Title ` +-� 0 AM AM <br /> 1 , • 2 0 0P � 1 � � 0P <br /> 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 /> Active Q Passenger • Generator Q Outdoor <br /> o NAGPS Latitude Q Closed Q Altered Q Hauler Q Indoor <br /> O Q Inactive I* 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 0 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 I 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 /> 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 EXT) 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 /> W <br /> Q Q 14 CCR§18461 -Manifest_System Requirements for Waste Tire End-Use Facilities <br /> Q O 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 /> Inspection Form Included: �Q ,\ /'� �{/ _ �/{,� ? <br /> Comments Included 1 V /���/!rV /%'/LRN' ���7""—3z,3 A <br /> B ss ep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect: � we 9fEXAMPLE 1 2 3 <br /> 0 White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA 0 <br />