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Waste Tire'RAey & Inspection ReputA Inspection Report Number <br /> CalRecycle State of <br /> CalRecyclel1fornia 181(Rev.10/10) S �/p �y 11 - 1196692 <br /> Dept of Resources Recycling and Recovery(CalRecycle) su• v ey Fo Form 1 1 — Page 1 <br /> Part A-SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � � �+, t,� -3 - O -1 Inspection Type(Fill one) <br /> Site Suffix: `'� _I l '0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: ��„y U`� CC <br /> Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �7 Inspected By Inspector <br /> 5 �� e�a� ,Tu.c. 3 `_ - 1 C AT T v <br /> Physical Address <br /> 153 27 - - - -- <br /> 01s205 Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 1 d QPM 2 d ® 49 PM <br /> S r p <br /> CA <br /> --- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 2 ' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' 0 Active 0 Passenger • Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned • OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Autp 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 • 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 /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / / m <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 EXn N <br /> r <br /> a <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 /> 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 1 Q 1 Other:§ <br /> z <br /> Comments &C-A&R- ©vim •RS 6C& <br /> Inspection Form Included: Q <br /> 2. -4Z-328 <br /> Comments Included:- <br /> �>� <br /> usiness Rep's Signature Phone Number Inspector's Signature Phone Number <br /> - 62081 <br /> INSTRUCTIONS N BACK Correct:41 Incorrect: ZX <br /> E X A M P L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />