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0 Waste Tire Sark Bey & Inspection Report inspection Report Number <br /> CalRec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I 1 1230176 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-S <br /> ur <br /> vey -----BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- t � .,� � � � � _ � ` Inspection Type(Fill one) <br /> Site Suffix: i I*Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: y� �� C k Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> jrNy\e �t��' I�7-t e <br /> Physical Address - ® �.� % �J <br /> 2.'i �7 1-7 <br /> Inspection Date <br /> '1 Time In Time Out <br /> Business Rep Title *AM 0 AM <br /> i 3 O O PM ®PM <br /> — Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 4 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> _1 40 Active Q Passenger 0 Generator 0 Outdoor <br /> Q Closed Q Altered <br />. GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive O 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 0 Other %& tSa rl& <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 /> 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 /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q 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 is In Compliance-No Violations o <br /> 1010 Other: <br /> Comments +�_ ��y�Q �,���G T�C'� `�h5p-eC�jp✓� �'i� �j� 'i 1o\t5 Ca.R� �, <br /> Cir. . <br /> Inspection Form Included: <br /> Comments Included: ,Jtoe <br /> / Q <br /> A,inessep's Signature Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X74) q]jEjXjAjMjPjLjEj 11 2 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />