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Waste Tire Survey & Inspection Report Inspection Report Number <br /> calRec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 11 1245259 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 7o Inspection Type(Fill one) <br /> Site Suffix: I 5 7 , Routine Q Re-inspection Q Referral O Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: ®Ck Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address MA T7 (J <br /> 227 W • L�V�Se- - <br /> Ck 9 Inspection Date 0 (� / I -2- / 1 <br /> Time In �j Time Out <br /> Business Rep Title 0 AM `� O AM <br /> 0 0 PM L d 4W PM <br /> �,., �nQG <br /> 3�� --�� 0.'� -- -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 9 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger 0 Generator 9 Outdoor Z <br /> O Q Closed 0 Altered H14M <br /> GPS Latitude 0 Hauler )Klndoor <br /> O Q Inactive 10Truck <br /> Longitude - Q Planned a OTR 0 End-Use • Containers <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet i 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 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) A <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <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 Q 1 Other:§ <br /> Comments <br /> Ag <br /> Inspection Form Included: Q CZ09/sSS (�Zc�y • p l/ ? 6 <br /> Comments Included: ACV l <br /> Business Rep's Signature Phone Number Insp toes Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />