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Waste Tire Suo vey & Inspection Report Inspection Report Number <br /> CalRecycle state of California — <br /> Y CalRecycle 181(Rev.10/10) �urVey Fora Page I11242105 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- y (�y ( t-J' Inspection Type(Fill one) <br /> ` <br /> Site Suffix: 7 6 � � a � ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ) If Referral,choose referral type(Fill one) <br /> Identifier: .j,e,✓1 �� j ✓rte L��•[J Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> T1�\ cc ��v✓111 - L D <br /> Physical Address Jim C5 l.2-/,,/�-} <br /> 60-7 &,-l k A -e- J <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 4'AM ff ii ®AM <br /> ( • /, L 3 Q PM l 1 '.� O PM <br /> .�tJ�C�✓l .�1�ylGri� C.�t�V�� <br /> Operational Status Tire Type Business Role Storage Type <br /> (FII all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) (Fill one only) <br /> ® Active Q Passenger ® Generator Q Outdoor <br /> �� <br /> Latitude O Q Closed Q Altered A(14 <br /> G Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®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 Exp <br /> a <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 /> ul <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 1 Q 1 Other:§ <br /> - z <br /> Comments <br /> Inspection Form Included: 0 Z u <br /> Comments Included: md <br /> Business Rep's Sig re Phone Nuber 1 p tor' S' n ure Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect: E JXJAJ P E 1112 3 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L ® ■ <br />