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Wasteifornia <br /> Tire Sruivey & Inspection Repor, Inspection ReportState of Ca {Number <br /> CalRecycle CalRecyclel181(Rev.10/10) 1_ vE=1 7 6 8 1Dept of Resources Recycling and Recovery(CalRecycle) Su rvey Form Page t <br /> _ ._ BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- p Inspection Type(Fill one) <br /> Site Suffix: ` , �, j d l It Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �Cl � of Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name/ y �, Inspected By Inspector <br /> r1 '%rl��5 V 1(ry Tp Cir C�Ce(� aJ ICJ�f�-1 I �n <br /> Physia tJAddress ` ( 7-11 r�y«jj �„G <br /> Inspection Date <br /> IZ <br /> II-An- Kiri-I 6A Oj I AC6 SCC JJJ o� l <br /> Time In Time Out <br /> Business Rep Title % O ® PM I �`, PM <br /> ' U � © �'r 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 /> r 0 Active 0 Passenger ® Generator ® 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 Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ® 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 Ae-fu,,'( I +' .` <br /> Q Service Station Q Hauler Q Agriculture Q Shredder S Other V1 � (e <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 Q - Q Notice Of Violation Q Extension <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 M / m / 7 <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 EXn N <br /> a <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 IS In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> Inspection Form Included: Q �aO <br /> Comments Included: ' 7 <br /> Bu mess Rep's Si ature Phone Number s o gnature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: � W g E X L E 1 2 3 62081 <br /> 0 White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />