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Waste Tire S ey & Inspection Repo, Inspection Report Number <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) 11 - 1176408 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> BLUE OR BLACK INK PEN <br /> Part A- Survey_ <br /> Business Profile Inspection Details <br /> TPID- O � - O � Inspection Type(Fill one) <br /> Site Suffix: I Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ( JQ Ltl1 n leu n� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 l Inspected By Inspector <br /> 5Address Tf u <br /> Physica I I 1 &_n Es c jjjo <br /> Inspection Date <br /> G�Q "�0 rN `l Time In Time OutO <br /> Business Rep Title I /� f ® AM *AM <br /> 11' r V I S O PM 1 O �J O PM <br /> Q It ev, �'�S 5 lti,n V 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 (Whole/PTE) <br /> 8 Active A Passenger 41 Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer IS 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 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 <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> a <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <br /> W <br /> Q O 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:§ l II <br /> Comments '-L, !'c, 1� �--� �LLnz���i/yl � �,LL�c• .t <br /> (j"_uS Of Conc9Till <br /> Inspection FormIncluded: Q 'r <br /> Comments Included: ®I <br /> L usiness p's Signature_ Phone Number Insp tor's Signature -_--hone Number <br /> INSTRUCTIONS ON BACK Correct:9 Incorrect: � , , <br /> E X A P E 1 : 213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co y:LEA © ■ <br />