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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle CalRecycle 181(Rev.10/10) 11 - 1210289 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 BLUE OR BLACK INK PEN <br /> Part A-Survey --- <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: Ll 0 C) I a Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: L"10CA_Ct"1N\_ 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Klavwc-A 6vybc,, ).X!s <br /> Physical Address S l t Al-19 ULA <br /> Inspection Date <br /> On-V1,k c C\- CA 1533-7 Time In Time Out <br /> Business Rep Title 0 AM Ca _ 0 AM <br /> 0 PM <br /> e ® PM <br /> Rex- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) / oo (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> * Active 0 Passenger IV Generator 41 Outdoor <br /> GpS Latitude 0 0 Closed 0 Altered 0 Hauler 0 indoor <br /> Longitude 0 0 Inactive ® Truck 0 End-use ® Container <br /> 0 Planned 0 OTR <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 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Datem / M m N <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred CalRecycle EnforcementLu <br /> Lu <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators (Q In Compliance-No Violations <br /> 0 0 Other:§ <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: 0 usiness ep's Signature Phone Number 1TFp6ec1Vr1S t e e Phone Number <br /> I 1 1 62081 <br /> INSTRUCTIONS ON IB lCorrefte incorrect: [E I X rA P - E <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pin kC__�. ® ■ <br />