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Waste Tire Sup vey & Inspection Report Inspection Report Number <br /> State of <br /> CalRecycle CalRecyclelifornia 181(Rev.10110) <br /> Survey Fora - Pagel I1 - 1177959 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1' 0 I Inspection Type(Fill one) <br /> Site Suffix: "� $ Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local n �'^ ) If Referral,choose referral type(Fill one) <br /> Identifier: �w� J (01A 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 6 Inspected By Inspector <br /> Physical Address <br /> 'D(3<j31� c . A C- In F <br /> � <br /> C� � ���� Inspection Date <br /> S(A <br /> Time In Time Out <br /> Business Rep Titlen J, 0 0 AM C 0 AM <br /> .L ® PM J ® PM <br /> S�,n� eo�e,1,\ cr�� �- m c. <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 5 ,} (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' l 0 Active 18 Passenger ® Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years W) <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 1 0 1 Other:§ <br /> Comments �� % 1 J �l ,-1 <br /> n 1 N <br /> Inspection Form Included: 0I� , <br /> Comments Included: AJ 8 �Aq <br /> Busine s ep's Signature Phone Number Insp toy's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: �C E X A L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink C y: ® ■ <br />