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® Waste Tire SL. i/ey & Inspection Report Inspection Report Number <br /> CalRecycle State of California — <br /> CalRecycle181(Rev.10110) Survey Form - Page 1 1 1177534 <br /> Dept,of Resources Recycling and Recovery(CalRecycle) <br /> -Part A=Surve - - BL-UE-OR-BL-AC-K-INK PEN — <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: O Z g �77 v 0 1 *Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ir\ J �,��� coVnA�x Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> 5SS 119. �I.o�.:v, ��• <br /> "S'13 <br /> Inspection Date / 'Z / l 3 <br /> M a1(��e C� 336Time In Time Out <br /> Business Rep 0 AM 0 AM <br /> 2 ' PM ® PM <br /> �ca mss\ O <br /> .Operational Status Tire Type Business Role Storage Type <br /> 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> 0 Active 0 Passenger Is Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GP� Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> IS 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 • 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 Notice Of Violation Q Extension <br /> 0 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 /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date / m m a <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) 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 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators IN In Compliance-No Violations o <br /> Q Q Other:§ I <br /> `` <br /> Comments (2 V-\!5 O r o 11 NC) C'� ��S &'Tse a.>n ('k ��Q <br /> C <br /> l�JC� V%O11t7AC3my s o c cyC tonCe-(-)n <br /> Inspection Form Included: Q _ 2 <br /> Zo$-t <br /> -3 8y <br /> Comments Included: usin s 9Crect::0 <br /> ure Phone Inspec or s Signature one Number <br /> 62081 <br /> INS T RUCTIONS ON BACK Incorrect: E X A M P L E 1 2 3 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />