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Waste Tire Su. Bey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 - 1177514 <br /> CalRecycle 181(Rev.10/10) <br /> (Cal 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- p t1 Inspection Type(Fill one) <br /> Site Suffix: �l l ( I ® Routine Q Re-inspection Q Referral Q Observation <br /> Locale ) If Referral,choose referral type(Fill one) <br /> Identifier: Su() —Jo L(+!\ C(��,t�l Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name JJ Inspected By Inspector <br /> C- G60TTO1 <br /> Physical Address <br /> 1 <br /> Inspection Date I l � L 3 <br /> Lchro� CA I C,33V 1 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O V ® PM 0 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 Q Passenger If Generator Q Outdoor <br /> � <br /> O Q Closed Q Altered 1�1�"1 <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 8 Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) Po kJ 4 <br /> Q New Tire Dealer Q Auto Repair 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 6 Other b14li6�,o <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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle iM <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <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 /> 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: l-§ <br /> z <br /> Comments CZ.O�}i N.., w IAZJC, �� ) c� �n S ' � T_l�1��i� like U►TA �[1 r 1.9-- <br /> 11,1fA n0�t4�'- <br /> Inspection Form Included: Q <br /> Comments Included: <br /> / B ignature Phone Number Inspe is Signature hone Number <br /> k' v 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: 'z;' E X I A1 1 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop :LE �� <br />