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® 0 Waste Tire Survey & Inspection Report Inspection Report Number <br /> CiRecycle State of California I 1 - 1196616 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A BLUE OR BLACK INK PEN <br /> -Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection <br /> Inspection Type(Fill one) <br /> Site Suffix: � LA CA3 b 0 ` * Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 0,g A e6vtil6Gr,,, 3 J ( ARA-MaLLI <br /> Physical Address � <br /> � L <br /> (23R5- c JAS'( �ek- <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> ` --t 9 PM Q PM <br /> Jev��,Itiv 6;v+iewe7,., ACS _ <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 /> O Active Q Passenger ®Generator Q Outdoor <br /> A <br /> O Q Closed Q Altered "'1~ <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive Q Truck <br /> Longitude - Q Planned • OT Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q 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 / f _- <br /> Q Service Station p Hauler Q Agriculture p Shredder ® Other &C'A� &Jb- WJAI. 1 W_ <br /> Part B - Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA 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 /> Q Q 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 a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days {Required for NOV or EXE N <br /> r <br /> 7 <br /> 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:§ <br /> Z <br /> 4 <br /> Comments <br /> Inspection Form Included: Q Z0q ^�ogCty <br /> Comments Included. ® I <br /> Busi ess Rep's Signature Phone Number I sp t r' ig ure Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: E X A P E 1 2 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator PinkC LEA ® ■ <br />