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Waste Tire Su,ve & Inspection Re ortAnspection Report Number <br /> CalRecycle State of California Y <br /> Y CalRecycle 181(Rev.10/10) 11 - 1242459 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection C - O Inspection Type(Fill one) <br /> 7 <br /> Site Suffix: L J 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local , If Referral,choose referral type(Fill one) <br /> Identifier: �co J 0tj qLt � n�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> U ab'Ies Tc, 105 3 q - C�ScOTTO <br /> Physical Address <br /> 53141 _5_ '�Cck'ol <br /> --I'1 ck m c J 3xl� Inspection Date g / Q <br /> 1 ` Time In Time Out <br /> Business Rep TitleI Q !, 0 AM < J'� 0 AM <br /> (J 0 PM l 0 J V 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) � <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � (7 <br /> A Active Q Passenger • Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q 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 /> 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 /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle j <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 GeneratorsIS In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments aL ,�; <br /> 01� �na_S1a7us i�e�J�; <br /> N r U,wev6 Ih 7' co,)cern <br /> Inspection Form Included: <br /> Comments Included: ® <br /> Bus ess Rep's Signature Phone Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X AM 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: EA <br />