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Waste Tire St' iey & Inspection Repor' Inspection Report Number ■ <br /> cle State of California <br /> CalRecycle CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1177578 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` 20Inspection Type(Fill one) <br /> Site Suffix: 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 6k.5w � Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name tI <br /> Inspected By Inspector <br /> Physical Address -3 - O A o-j <br /> Inspection Date -3 / 1 3 <br /> M ask-'eco C;' 95337 <br /> Time In Time Out <br /> Business Rep Title0 AM 0 AM <br /> ,N <br /> Z ' Z * PM 3 © 0 P <br /> J os' J C-co 6 e,f <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 /> *Active ® Passenger 0 Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> o Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> -i New Tire Dealer 411 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 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 Q PRC§ - Q Notice Of Violation Q Extension <br /> 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 N <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 o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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:i§ <br /> Comments VZC9y A � h�2 iY�SpQC-t�G��•• Wa-S ['�.-c9�r-�2 O� ��^� � C�,c�.� .� <br /> (.'r 1,N-cf-c s rQ CcoV-'Ce.(`V-\ <br /> Inspection Form Included: Q j 11 <br /> Comments Included: • �S- t-- <br /> Bus ess ep's Signatur Phone Number Inspe or's Signature Phone Number <br /> �— <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P L E 1112131 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />