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2 Waste Tire SL_ iey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State w Cal'dornia I 1 - 1178013 <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 m Inspection Type(Fill one) <br /> Site Suffix: ` •Routine Q Re-inspection Q Referral Q Observation <br /> Local ` / _ If Referral,choose referral type(Fill one) <br /> Identifier: SAt1�0 I rl U�,IA\ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> ,(�GJ T f ctn SP J)rt wVj'-G f - P <br /> Physical Address S� d <br /> Inspection Date <br /> c� lvJ �� �s3o�l lJ CCV77\11 <br /> Time In Time Out <br /> Business Rep Title ® AM I h c ® AM <br /> lV v QPM l V `� 0 P <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 Q Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GAS Latitude Q Hauler ® Indoor <br /> O Q Inactive ® Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer ® 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 Notice Of Violation Q Extension <br /> Q Q 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 O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q O 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 EXT) n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O O 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 /> Comments r <br /> ANA <br /> f\�� vIA I\lAu1s -UJ Lx-IeUS lul1�U(1 <br /> Inspection Form Included: Q ' <br /> Comments Included: <br /> ® �3 2 � U <br /> ABusinessp's Signature Phone Number Inspe is Signature 9�Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X � � E I X I AMP E 112131 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy L ® 0 <br />