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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CaIRCC cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Firm - Pale 1 I1 - 1177871 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 5 a 5 y _ Inspection Type(Fill one) <br /> Site Suffix: • Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalG ��-� �, ���� If Referral,choose referral type(Fill one) <br /> Identifier: J V �p 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> / <br /> Physical Address <br /> X15 �- E�'�;��-n� Cn <br /> Inspection Date 1 � / o / <br /> (re_r\(� (A q <br /> Time In Time Out <br /> Business Rep Title !� O AM L 5 0 AM <br /> 6 PM <br /> �J (9 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 /> ® Active O Passenger 0 Generator 41 Outdoor <br /> 0 0 Closed O Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - O Planned ® OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 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 O Agriculture 0 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 � Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <br /> W <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments e. a^ 1 w Ctrl <br /> �0�1�O A WkSOO�CA <br /> No \1; 0la6,l cons A r1(eUA 6�- <br /> Inspection Form Included: Q < / p - <br /> Comments Included: ����/v 0 Z _ <br /> Busin ss Rep's Signature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X NJ E X A L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pin EA <br />