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Waste Tire S,. Bey & Inspection Repor, Inspection Report Number <br /> CalRecycle State of California — ■ <br /> CalRecycle 181(Rev. (Ca[ Survey Form - Page 1 I1 1210536 <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 7 _7 - © Inspection Type(Fill one) <br /> Site Suffix: A Routine Q Re-inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: 50,VX �dpq� 6w% CO��,� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name L Inspected By Inspector <br /> oy�.z �kd,\5 hoc k�•w eSkcSz ,3 9 - ` o MAT <br /> T v <br /> Physical Address <br /> LC> Ke kk1 eVV\O y\ L•N <br /> C� ��2�1 a Inspection Date 8 / 7— 7 / 1 3 <br /> Time In Time Out <br /> Business Rep Title AM 46 AM <br /> l ' O Q QPM © QPM <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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> O 0 Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q 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 /> 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 <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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE n <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 dpIn Compliance-No Violations o <br /> Q Q Othe�lr:�§ -\ �j , <br /> Comments �yce �1�1�S�2G���Y�p��(�1L� % - 0.`�r�c� �K - <br /> O C kces-S c C_0"-L`C C v\' <br /> s� c�\• Vb'S C7bc'e_c_'JA "c-e-S ov.sk-'V, <br /> Inspection Form Included: Q <br /> Comments Included: Q 2� " 4"`'^3Z�'"1 <br /> Business Rep's Signature Phone Number In�,r'4( nature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: (� E I X A JMP I L I E 1 111213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA �� ■ <br />