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Waste Tire'%Wey & Inspection Repft <br /> Inspection Report Number <br /> rniaCState of California <br /> alRecycleCalRecycle 181(Rev.10/10) <br /> Survey Form - Page 1 1 - 1176842 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- V7 w Inspection Type(Fill one) <br /> Site Suffix: l + Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: G.0 04jj IAJn CvUln Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> A%'() <br /> Physical Address I ) � <br /> Inspection Date <br /> Time In v Time Out <br /> Business Rep Title o A AM O AM <br /> Q PM I O 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Q Active 0 Passenger Q Generator Q Outdoor <br /> O 19Closed Q Altered /V <br /> GPS Latitude NIA Q Hauler� Q Indoor <br /> 0 Q Inactive 0 Truck ` <br /> Longitude - Q Planned Q OTR End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair I* 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 O 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 /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> 0 O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> O O Other:§ <br /> Comments11) 1 f N <br /> e� ))00 t , a 0,I td" d- cors Cit,T n <br /> *fl -e 4 S I f�)o Tesco. <br /> Inspection Form Included: QAJ6 <br /> `O _ <br /> Comments Included: b �InBusiness Rep's Signature Phone Numberp is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: N E X A M 1 213 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L <br />