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M 0 Waste Tire SL. 4ey & Inspection Report Inspection Report Number <br /> Cdeccle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 - 1210405 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- `` Q 1,�` Inspection Type(Fill one) <br /> l <br /> Site Suffix: 5 a 0 5 © ® Routine Q Re-inspection 0 Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: �0�,A 10 q q 1A11 J1 Q CHP 0 CalRecycle Q Complaint Q Educational Visit Q Other <br /> 6 � <br /> Business or Facility Name Inspected By Inspector <br /> PhysicalAddress , E,3( TTv <br /> Inspection Date <br /> fK �I C A aS?,b <br /> Time In Time Out <br /> Business Rep C 1_ Title ® AM ` 4 AM <br /> Ol1 J�t'� f\ CU /�, ., S Q PM I O S Q PM <br /> v W �� 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 /> Q Active Q P e'n�g]er Q Generator Q Outdoor <br /> - O 0 Closed Q Altered ,v Jn N_y-�� <br /> GPS Latitude Q Hauler- Q Ind000 <br /> O 0 Inactive Q Truck <br /> Longitude - 0 Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 0 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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q 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 N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <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 /> Q Q Other:§ j� ,A 6" <br /> - l- ��- <br /> Comments 1 f-Q (-, � .u'1 cA 1f CA n1 S 1 o � K <br /> V Q- <br /> :_ 4a� I, A)AnA tAAS )OXJ�N o �40y' Js �.w tri- wac o <br /> I(obLt34 L 4st C7 L ' <br /> z D • �16-(t UjC4.s B12101». CkoT?:z <br /> Inspection Form Included: 0 ,, 4Acf7r111/ <br /> Comments Included: 0 - � <br /> 4usss RepVi,4gt ure IIJJ P one N mber Insp tors Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: g E X A IM P 112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy ® ■ <br />