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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRec Recycle. State of California — <br /> Y . CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1230146 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A_-Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> Site - 3 L n I S _ 5 1 Inspection Type(Fill onesp Q Q <br /> Site Suffix: ill b Routine Re-inspection Referral Observation <br /> Locali ������ If Referral,choose referral type(Fill one) <br /> Identifier: SlJ�(� J0CL �t r1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name \ Inspected By Inspector <br /> P<cM \e�' C�nc�S�Q,C' 0fTfC4 I <br /> Physical Address q -3 es G. <br /> Inspection Date <br /> �c�r✓� C <br /> Time In Time Out <br /> Business Rep Title ,1 1 : V AM 1 4P AM <br /> M tA& `"V (� Qi As AU,I-13C r 0 PM 1 O 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) r7O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active & Passenger ' Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q 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 Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body ! 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 <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 EXE N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <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 /> CommentsQ 1 W_yt INC 1W�� �f L 1 T1S ' �� 0r� N <br /> ` 1 Wj a�1 <br /> ­41 d1s oI C&JM-'4 Cun Ce ro. <br /> Inspection Form Included: Q i <br /> Comments Included: ® // �/ �G✓ - -\ ---� <br /> Business Rep's Signature Phone Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:is Incorrect: X ( V P E X A M L 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LE <br />