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Waste Tire Survey & Inspection Report Inspection Report Number . <br /> Cal Recycle state of California 11 - 1196394 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 0 � (�, ' o O Inspection Type(Fill one) <br /> Site Suffix: `1 Q Routine Q Re-inspection 41 Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S Ct ry J vCK 111 1__-' Q CHP 0 CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` <br /> Inspected By Inspector <br /> nuc IMy)0 es <br /> Physical Addre - Co TT <br /> 53p� Inspection Date <br /> 9 <br /> Time In Time Out <br /> Business Rep Title , 0 O AM O AM <br /> to W n e r B PM a V A PM <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 /> ' 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> o 0 Closed 0 Alterdd�{ IZj 1�'1, <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair ® Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 � Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 10 In Compliance-No Violations o <br /> 0 0 Other:§ _ <br /> ` 1 <br /> Comments _TKL_16S��y fJLTu/�. _ � .L�Q (()-�,�,��a��-(�o� <br /> su�Cl- Z_lAiCA (�1C �10_0Imo- ms <br /> a c.�"y'kja �' r b�2 (_7I1 °1) ' <br /> ����, ,U�� l' <br /> Inspection Form�nc <br /> ncluded: 0 , <br /> Comments luded: 0 ~ <br /> Business Rep's Signature Phone Number Insp or's Sign-, Phone Number <br /> INSTRUCTIONS ON BACK I Correct:0 Incorrect: EJXJA� 1 1112131 <br /> 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co L <br />