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Waste Tire Su. Bey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 11. 1226586 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Inspection Type(Fill one) <br /> Site Suffix: l "� �(1 • Routine Q Re-inspection Q Referral Q Observation <br /> Local ® 1 If Referral,choose referral type(Fill one) <br /> Identifier: 5�� JQ(�q)�1 n 1 AL1 n►U Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name L I Inspected By Inspector <br /> 1 <br /> Physical Address �S <br /> a�3� 1 w. w�►s�,��k v� � . # N <br /> C \ Inspection Date <br /> 3\ o C��LkO e� ZU3 `J <br /> Time In Time Out <br /> Business Rep Title1 O O AM � r /1 0 AM <br /> ® PM J CJ Q PM <br /> --- <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 /> ® Active ® Passenger 40 Generator 0 Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive ® 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 Q Collection O Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other tb,l 0 VQ.551_1 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> _ — - 0 Notice Of Violation Q 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 /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O ® 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O l0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> O ® 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> W <br /> W <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 /> O O Other:§ <br /> Comments at <br /> p t a ',n 4. l�G.s�G �1 j� t�ec�Ci Un A t)af, <br /> t <br /> Inspection Form Included: Q , <br /> Comments Included: _41y)- - � '�� - <br /> Business Rep's ature Phone Number Insp or's Signature _ - Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correct.* Incorrect: I <br /> V\ E X A P E 1 2 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C EA <br />