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.0 Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle CalRecycle 181(Rev.10/10) Surve Form - Page 1F11 - 1210259 <br /> Dept,of Reacurcas Recycling and Recovery(,,,Racy,,,) y J <br /> Part A-Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPISite - T _ 0 Inspection0 RouinType0ill one) <br /> sP 0 0 <br /> Site Suffix: 1 Fj Ii 3 3 -f LLLCCC Routine Re ins action Referral Observation <br /> LocalC ` If Referral,choose referral type(Fill one) <br /> Identifier. -SC JOC1_t1A'1V Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ((( Inspected By Inspector <br /> [�R Physical Address <br /> 1 I Lfm <br /> LL`_a.- <br /> Street m <br /> Inspection Date <br /> =�`'�4�•`�!l c�t� <br /> State ZIP Code e Time In II„ oo II Time Out�ity <br /> Business Rep `Title AM ®AM <br /> O PM � � I (� O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) D� r� (O one only) (O all that apply) (®all that apply) .(Fill all that apply) <br /> Active Pas en er Q <br /> Generator Outdoor <br /> Closed Q Alter O AJIA- <br /> GPS Latitude ,{H�� ® Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — I. I. <br /> Q Planned Q QTR 0 End-Use Q•Container <br /> Business Type(Fill all that apply) . III <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet It Government Q Retreader Q Dismantier 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 ' C <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension ; <br /> N,. <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements DateJ I <br /> Q Q 14 CCR§18459.1 -•Tire Program ID Number from CalRecycle <br /> 00 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement f <br /> W <br /> 0 0 14 CCR§16461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ®.In ComP,lance-No Violations o <br /> 0 0 other:§ <br /> Z <br /> Comments ,(Low ' CMS �xU�iL A( yfU <br /> �I)) lt� t[Ytiia-- tri -_�C Va4..C�At ALJ <br /> `��1�1_-���—a►.l,r-�c�.c;� �-- �' c�o���, 136 l�6� . �I� ��t <br /> Inspection Form Included: Q 9 33-7 1`fir <br /> Comments Included: Q - <br /> ture Phone Number s e or gnat a Phone Number <br /> ass Re ' Ina 62081 � <br /> P 9 <br /> INSTRUCTIONS ON BACK Correct hcorrect:. �.��. E X R M E 1 2 3 <br /> . White Copy:Cal ec a Yellow Copy:Operator Pink Copy:LEA <br />