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02 Waste Tire Suil Bey & Inspection Reporl •nspection Report Number <br /> CalRecycle state of <br /> CalRecyclelifornia 181(Rev.10110) 11 - 1210385 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 -57, 5 3 3 2 � 1 Inspection Type(Fill one) <br /> Site Suffix: 4PRoutine Q Re-inspection Q Referral Q Observation <br /> Local �.-� If Referral,choose referral type(Fill one) <br /> Identifier: Ste,^ J 00Jt V%y\ V y Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Y�o� )Nvko C2"N-\'e_( 3 - O ` <br /> Physical Address 1 1 1V <br /> Inspection Date <br /> ''bCV\ C GS2yo <br /> Time In Time Out <br /> Business Rep Title �7 0 AM 1 ` 0 AM <br /> O�,,{r Z C` 0 PM I b O �PM <br /> UC` <br /> b --- t (/ -- Operational Status Tire Type Business Role Storage Type <br /> - <br /> Tire Count(Whole/PTE) t , (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> a Active 0 Passenger ® Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 9 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 /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years 8 <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:§ <br /> Comments y,,e>, G�D`n �'C.=_C!)Vj l S C <br /> JU s CXZ Cemeeirn <br /> Inspection Form Included: O C909) : a t <br /> Comments Included: '333-4•Qlf Za-1"�Og��Zff <br /> Usines Rep's Signatur I Phone Number Inspec or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />