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Waste Tire jurvey & Inspection Rep(Pi Inspection Report Number <br /> State of <br /> ® CalRecycle CalRecyclelifornia 181(Rev.10/10) — <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Survey Form - Page 1 I1 1242506 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I n C n O I Inspection Type(Fill one) <br /> Site Suffix: J "� 0 Routine Q Re-inspection Q Referral Q Observation <br /> Localpu1If Referral,choose referral type(Fill one) <br /> 1 <br /> Identifier: SOLO JOa ttln l(Y1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 06 <br /> Physical A ress - 6 V I �5�,(�TT <br /> �()Du 5 . c\-,A'4z-CL Le. <br /> LORI gSZ1,D Inspection Date � / 30 <br /> Time In Time Out J <br /> Business Rep Title I O ® AM 11 ® AM <br /> O 0 PM 1 C� �J Q PM <br /> \� S pU�ner <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) a (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 10 ® Active 0 Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 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 /> 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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXTJ 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 /> 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:§ 1 ], Ll <br /> Comments t11�i i \A7IVJCr St, 10SPG( ��� ��� On �Vl1 S j q, a, 4W)(,A -1 na <br /> Inca= � )US 6 cC <br /> N6 tOS 4A ,ZA& c-6 r)cern_ <br /> Inspection Form Included: Q A �,�0 <br /> Comments Included: <br /> Business Rep's Signature Phone Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK FCorrect: Incorrect: M E X AMPLE 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co y:L <br />