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■ nspection Report Number <br /> � Waste Tire Su. rey & Inspection Report � <br /> cle State of California <br /> CalRecycle - 1230363 <br /> Y CalRecycle 181(Rev.10/10) Survey Forme Page 1 I1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� Q � � _ a t Inspection Type(Fill one) <br /> Site Suffix: 1 l 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: %,3,%Y\ COVE Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address r� e <br /> 14� ivy 6�C7 <br /> S C 9 S2oS v <br /> Inspection Date C C / Q '2- , <br /> Time In Time Out <br /> Business Rep __``-- Title (� O AM e Z O AM <br /> S�¢kk C1��W�C.11� �6r�c>;an . PM �PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) A (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> - Z 0 Active Q Passenger a Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q 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 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 i Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT T 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 Y <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E)C7) 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 /> 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 /> Comments ` R� vl(� <br /> O <br /> S C <br /> Inspection Form Included: Q /� �Num! <br /> Comments Included: i&�tu <br /> 2b�Business Rep's Signature Phone Number InspP <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: IEIXIAIMIPILIEI 11 2 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />