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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle 11 - 1196658 <br /> CalRecycle 181(Rev.10/10) <br /> (Ca[ Survey Form - Page 1 <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 � 3 _ Inspection Type(Fill one) <br /> Site Suffix: -I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Localc If Referral,choose referral type(Fill one) <br /> Identifier: J0. aor d k `V\ C6 Vv, / Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name '"` Inspected By Inspector <br /> Physical Address 0 M Aj fi <br /> q52 A Inspection Date 1 2 / 06 ` <br /> C� uUTime In Time Out <br /> Business Rep Titlew O O AM O AM <br /> 0 PM is PM <br /> -'T", L�--ar-zoo Taw., c� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) r (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger 40 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive I* Truck <br /> Longitude - Q Planned 0 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 /> Notice Of Violation Q Extension <br /> Q Q 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 mol / mos / m <br /> 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 EXT) 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 Q In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments �.C� •V'�, �p.S�`2'LQ �V`SQP['�C�Y\ C���-G�V� `1��5 �a� <br /> Inspection Form Included: Q q6$-32 <br /> Comments Included: <br /> U <br /> OessK _s <br /> I Rep' gnature Phone Number Inspecto 's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: � � EXAMPLE 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />