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Waste Tire Sup Bey & Inspection Report Inspection Report Number <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 1210361 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUEAR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � � � 1 Inspection Type(Fill one) <br /> �Site Suffix: ( ! Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 50. 5,�,n m v`Y\ co Vy� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name `�`^� ` <br /> Inspected By Inspector <br /> Physical Address / t A <br /> 220\ VJ- W 0.5 •`c`�' '�i v-,d Inspection Date S � 31 / I 3 <br /> Sj ko C-V koY1 cA C!S 203 <br /> Time In Time Out <br /> Business Rep Title O O AM O AM <br /> 2 ' 49 PM O PM <br /> Vl0 V) �orSCj c�iSb <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) G (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I !Active I& Passenger &Generator 41 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned • 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 40 Others l(gyp <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I 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 /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> *In Compliance-No Violations o <br /> Q Q Other:§ <br /> z <br /> Comments 4�V1� Ove S <br /> Ay_TQ 0.5 r 2d - <br /> �� V�d�.a.�:on,5 o C` ('esu-S o� Coh,cei' ►n <br /> Inspection Form Included: Q <br /> Comments Included: 0 <br /> Busin ss s Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P L E 111273 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />