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M Waste Tire SL. Bey & Inspection Repori Inspection Report NL,,iher ■ <br /> CalRecycle State of California I 1 - 1226628 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK P E N <br /> Part A- Survey _ — - - <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: I Q l • Routine Q Re-inspection Q Referral Q Observation <br /> LocalC _ If Referral,choose referral type(Fill one) <br /> Identifier: Sun �U `'L� L©I-NL Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Old <br /> PhysicaAddress <br /> �1C.11l <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title ®AM ®AM <br /> l © Q PM / (.1 O PM <br /> -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> /�1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> •vf - <br /> ® Active Q Passenger ® Generator Q Outd or <br /> Q Closed Q Altered AIA <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) <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 ® Other U are-kezvo <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / [T] <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) 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 Q Referred/CalRecycle Enforcement <br /> LU <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities - <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:§ — <br /> Comments <br /> Inspection FormIncluded: Q _ 4*1:h4mel <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number I ctor' Si ure Phone Number <br /> INSTRUCTIONS ON BACK Correct:40 Incorrect: E X A M P L E 1 2 3 6208 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />