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Waste Tire SL.. rey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 1230410 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Survey <br /> -Survey_ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � S iy � � � � � � Inspection Type(Fill one) <br /> Site Suffix: b `-', 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sq y 1 VAS ��� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v Inspected By Inspector <br /> Physical Address 1'T <br /> 21920 X1., 0. WAY <br /> Inspection Date <br /> LI GS364 <br /> Time In � Time Out <br /> Business Rep Title 1 l 0 AM <br /> P 0. 1 0 PM I 1 ®PM <br /> � h�S �a��s �� <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 /> 8 Active Q Passenger 0 Generator • Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude _ Q Hauler Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned 0 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 ® tn.'UTO / k') 1 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS l <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 /> 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 a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXl) n <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 /> f <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 ®In Compliance-No Violations o <br /> 1010 1 Other:§ <br /> Comments <br /> wQJS hok(�O- <br /> ov�,S C �a-Scizwk0le C r` <br /> Inspection Form Included: Q <br /> Comments Included: ✓� `��' � <br /> usiness 06p'oigAature Phone Number Inspe or's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A M P L E 1112 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />