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Waste Tire SL.. Bey & Inspection Report inspection Report Number ■ <br /> Cal Rec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) I1 1226348 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 1 5 1 _ 0 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: 5 �(� J CC7 t' �t �VU n� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspector <br /> Inspected By p <br /> Physical Address <br /> N, MAIC <br /> C A g53-1-,)6 Inspection Date 3 / l j <br /> Time In Time Out <br /> Business Rep Title 0 AMO AM <br /> PM is PM <br /> Tl�f(� Mti�ncn0�r� Otlun�r's Sar+) <br /> Operational Status Tire Type Business RoleStorage Type <br /> Tire Count(Whole/PTE) C _ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> e Active ® Passenger 0 Generator Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude 19 Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude – Q Planned Q OTR Q End-Use I* Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station -0 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 <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 /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 EXE <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <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 Q Other:§ 1(� <br /> Comments \c-b-Akfa, S �1j 1 1 ,1 1S L r <br /> Inspection Form Included: i_ -'--7J-q� <br /> Comments Included: <br /> ...-(—'`J - <br /> _ Business Rep's Signature Phone Number Inspe is Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:9 Incorrect: ( E X A M L 1 2 3 <br /> . White Copy:CalRecycle Yellow Copy:Operator Pink Co y: © ■ <br />