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Waste Tire ju. ve & Inspection Re A# Inspection Report Number <br /> CalRecycle y p p -1176447 <br /> State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 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- i / - 0 l Inspection Type(Fill one) <br /> Site Suffix: ` 6- C ® Routine Q Re-inspection Q Referral Q Observation <br /> Local _^ If Referral,choose referral type(Fill one) <br /> Identifier: 4V� (:1��� �� ✓L Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> y Si�f,CX k clti '"" ' <br /> Ph 3 9 - ( v 1 A ISS Y►1Dl <br /> Physical Address <br /> o21oi E. rAcu"%'Pam•.. .. <br /> Inspection Date / Ll <br /> CA <br /> Time In Time Out <br /> Business Rep Title 1 ®AM j AM <br /> r`A+��C'.�.UCJ�, �Gt�' ✓ � l �/ � O PM l � QPM <br /> a <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 /> 0 Active ® Passenger V Generator 0 Outdoor <br /> Q 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 /> ® 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 /> 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 /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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:§ <br /> Comments <br /> Inspection Form Included: Q ��// <br /> Comments Included: ®- ���''llJ-Pgnature <br /> B iness Rep's Phone Number s e is ature Phone Number_ <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: ( ? E X MY L/E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pin Co .L A © ■ <br />