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Waste Tire Su. ✓ey & Inspection Repor Onspection Report Number <br /> State of <br /> CalRecycle CalRecyclelifornia 181(Rev.10/10) I1 - 1242438 <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- �7 ® I Inspection Type(Fill one) <br /> Site Suffix: / 10 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q� J©0— V�� cc V Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility�Name \ `� c� Inspected By Inspector <br /> Physical Addess� \Jit s�1 "�� <br /> 227\ W. Lov�Se. <br /> C l � Inspection Date c) 7 <br /> 5337� <br /> Time In Time Out <br /> Business Rep Tiittle,—, O ANI Z O AM <br /> vC�. 1"�lY�C1Y��< O * PM 7 ® PM <br /> �`� �� Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) r (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' b 0 Active Q Passenger 10 Generator I* Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude _ Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned 0 OTR Q End-Use • Container <br /> Business Type(Fill all that apply) t-tcV,ytCC�j <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet SP 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 Q Q Notice Of Violation Q Extension <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 / 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 E?Cn N <br /> V <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§184602-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:§ <br /> CommentsN <br /> Inspection Form Included: Q Z-�3) 5S 07 N <br /> L�6Z <br /> Comments Included: � �2$� <br /> Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: jEjXjAjM� PjLjEj 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />