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Waste Tire Survey & Inspection Report <br />CalRecycle State of California <br />CalRecycle Y81(Rev. 10/10) <br />(Ca[ Survey f=orm - Page 1 <br />Dept of Resources Recycling and Recovery(CalRecycle) <br />Part A - Survev <br />Inspection Report Number <br />Il - 1210590 <br />BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPID - <br />Inspection Type (Fill one) <br />Site Suffix: 02 ''I �i ( L i <br />® Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Local CC -- J� . <br />Identifier:�C�� ��vl�. t.E1l/YL' �J <br />Business or Facility Name <br />Inspected By Inspector <br />pep p <br />Physical Address <br />Inspection Date <br />G <br />CA R5ttC6, <br />Time In Time Out <br />Business Rep Title <br />! AM 1 AM <br />01 : � <br />A�t� t1u,Y ��Gi.�'� rS1T�. �,1�i�1►�'�' �C✓V�ZC� <br />v2 0 O PM O PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />® Active <br />® Passenger <br />I® Generator <br />® Outdoor <br />O <br />GPS Latitude <br />Q Closed <br />Q Altered <br />Q Hauler <br />Q Indoor <br />Q Inactive <br />Q Truck <br />O <br />Longitude - <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />® New Tire Dealer J9 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 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 />- - � Notice Of Violation 0 Extension <br />PRC § 42951 Waste Tire Hauler Registration and Transport of Tires <br />Q Q - <br />Q Q PRC § 42953 - Contracts with Registered Waste Tire Haulers. Compliance Deadline <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q Q 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements Date ® / M'_ZLjQ <br />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 EX77 <br />® 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 <br />Q Q 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br />Q 1 Q 1 Other: § <br />Comments <br />Inspection Form Included: Q <br />Comments Included: ® <br />B ep's Signature PhoneNumber. Inpe orign ure Phone Number <br />INSTRUCTIONS ON BACK I Correct: 40 Incorrect:] E X A M E 1 2 3 62081 <br />■ White Copy: CalRecycle Yellow Copy: Operator Pink py: ® ■ <br />