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i <br /> Waste Tire Sig. ✓ey & inspection Report inspection Report Number <br /> Cal Rec cle. State of California _ <br /> Y CalRecycle 181(Rev.10110) Survey Fora Page 1 111242328 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- g U _ ' Inspection Type(Fill one) <br /> Site Suffix: * Routine Q Re-inspection Q Referral Q Observation <br /> Local C �� I If Referral,choose referral type(Fill one) <br /> Identifier: Jan J o IA t r� �du�+ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name t Inspected By Inspector <br /> Physical Address U7iT 0 <br /> 3D-00 S . E Qosorip <br /> Sko&k0n �� h�o� Inspection Date <br /> Time In Time Out I <br /> Business Rep Title (l 0 AAM V ® AM <br /> A <br /> r,f c r•cit{�k J PM <br /> OCA,�,t( Q 1 sc' 11 r <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) YS (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Q Passenger 0 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> G�� Latitude Q Hauler Q Indoor <br /> 0 Q Inactive 0 Truck <br /> Longitude – Q Planned Q OTR Q End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 0 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 /> QQ 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 EX7) n <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 /> 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 VCU✓I G Ai je— 1 P�0 �'� tY.T r 115 Q 'C�� arYl V1 114" <br /> A OJ ( Ietns n+ cUr)CE'[n <br /> Inspection Form Included: QI101L <br /> + <br /> Comments Included: �Q 9 <br /> Busi ss Rep's Signature Phone Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: zX W E X A M P L 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: EA ® ■ <br />