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Waste Tire Wey & Inspection Repoi Inspection Report Number <br /> Cal6ec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 1 - 1186139 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey _. BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 1 IVh Z ' Is Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ZP,n),P., f /1-- <br /> Physical Address 00 1 tJ � �G 1'V e_1> <br /> J SeC Inspection Date o i) Z Z / 13�A 157,o6 <br /> Time In Time Out <br /> Business Rep Titleg� nn ) C� (+� AM 40 AM <br /> 1 p V y{ ✓ PM 5 Q PM <br /> 0�n� I� � rV'1L. s) M /' -- <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 /> GPS Latitude &Closed O Altered O Hauler 01 ndoor <br /> O Q Inactive O Truck <br /> Longitude - Q Planned Q OTR O 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 O Collection Q Crumb Rubber ) l <br /> Q Service Station Q Hauler Q Agriculture O Shredder I, 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 0 Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> OO 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date / <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> m m <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> a <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 0 Other:§ L - -- - -- <br /> Comments <br /> _r10 <br /> T y�l LIU <br /> � � � J\1.C,L G'`7A� L' �i � x.71 v'I V; <br /> -0 l�I D ate. ) C4G T L <br /> 00r �, liDjG G�L Gbt <br /> Inspection Form�nc <br /> ncluded: O t/ f If .3 <br /> Comments luded: Q - - <br /> Business Rep's Signature Phone Number Inspec or's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct: Incorrect: IEIXIAIMIPILIEI 11 2 3 62081 <br /> White Copy:CalRecycie Yellow Copy:Operator Pink Copy:LEA <br />