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Waste Tire Sui vey & Inspection Report Inspection Report Number <br /> cle State of California <br /> CalRecycle Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 - 1210391 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I 6 1 C 1 _ O 1 Inspection Type(Fill one) <br /> Site Suffix: 7 ` Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: (�CA.q\ J pry Q\,^ �IJ w� -r Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _ l r Inspected By Inspector <br /> 1?0�-OA 39 - � r� � MATT U <br /> Physical Address <br /> Inspection Date S / 'j / 3 <br /> S33 0 <br /> Time In Time Out <br /> Business Rep Title ' t O d *AM O AM <br /> QPM 0P <br /> C'C>YV0. — - �a�1 Se( 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 /> toJ `Active Q Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned @ OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) Cotw-.4 <br /> ; <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 18 Other �<<� by` ��2V'v <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 <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 m / m / m <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) <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 /> Lu <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <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:§ ,_ 1' 1 t <br /> Comments n ��"\� L Com! _ kk V-P_ --Ansp�c�_01!\ k9_�b Vl ibis 0.� `-CInQ <br /> k le- 1 aA_'e_ 6egr\ 6 cre.0 <br /> 4 <br /> d io e-CL's ep�- covtcep^ <br /> Inspection Form Included: 0 <br /> Comments Included: / <br /> Business Rep's Signature Phone Number lnspec or's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: W IEIXIAIMIPILIEI 1112 3 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />