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M <br /> t <br /> Waste Tire Su. Bey & Inspection Report Inspection Report Number ■ <br /> CalRec cle State of California — <br /> Y CalRecycle 181(Rev.10110) Survey Fora - Page 1 I 1 1177716 <br /> lR <br /> Dept.of Resources Recycling and Recovery(Caecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- i Inspection Type(Fill one) <br /> Site Suffix: 1 Z Ll - © C ,® Routine Q Re-inspection Q Referral Q Observation <br /> Local ` �� ��� If Referral,choose referral type(Fill one) <br /> Identifier: �C � Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 1 � � ASA � �Z� <br /> Physical Address 1 <br /> '/03)V 3-Ce�c7vy AV-zf- <br /> Inspection Date 5 <br /> CA <br /> Time In Time Out <br /> Business Rep �L Title <br /> ll e, O AM O AM <br /> GAY U�1CJCLAIA v- O PM '�- 3 ® PM <br /> ,� <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 /> c ® Active ® Passenger 0 Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive Q Truck <br /> Longitude - ® End-Use Q Container <br /> Q Planned Q OTR <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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder © Other k-6 <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q O 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) <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 L <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> Inspection Form Included: 0 f <br /> Jp 73 <br /> Comments Included: <br /> BmnesWRep1s Signature Phone Number Ins cto re Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: 7X:*Y] E X A L 1 273 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co :L <br />