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® Waste Tire Su. Bey & Inspection Report Inspection Report Number <br /> Cal Recycle State of California 11 - 1226378 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: l b 0( l Q Routine Q Re-inspection a Referral Q Observation <br /> Local `c��� If Referral,choose referral type(Fill one) <br /> Identifier: tel;- V� �J1�/\ ���'�' Q CHP Q CalRecycle0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name ] Inspected By Inspector <br /> Physic I Addre��� ` /TYU 1'yl CSL <br /> i 5 qo <br /> y� Inspection Date j <br /> Time In Time Out <br /> Business Rep ,�T}itle /� 0 AM c�l O AM <br /> �z- 1 Ptd l.Gt/Y�C' PM l PM <br /> e4 r1C't� Operational Status Tire Type Business Role Storage Type <br /> ' ' ' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count hole TE) <br /> ® Active Q Passenger �► Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® 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 0 Other I�(_nL<'- <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS *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 /> Q Q PRC§42956-Registration/Decal in Vehicle m <br /> ® Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> • Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXE <br /> Q Q <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 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 /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance-No Violations o <br /> Q Q Other:§ - -- z <br /> Comments <br /> -- <br /> Inspection Form Included: ® ` J ' <br /> Comments Included: ® t� <• <br /> Busin s ep s ig ature Phone Number Onatu& <br /> PhoneNumber <br /> �, 62081 <br /> INSTRUCTIONS ON BACK Correct 0 Incorrect: X NJ E X A ML E2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />