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E 0 Waste Tire f&ey & Inspection Repo"wnspection Report Number <br /> CalRecycle s,-tCalecyc-,iforn'le 181 Rev.10/10) — ■ <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form 9 9 — Page 1 y� 1177880 <br /> Part A -Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> O <br /> Site Suffix: 1 �J "� l', 1*Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �- ) If Referral,choose referral type(Fill one) <br /> Identifier: Sc,) 30 jAjf'\ &k0+1A 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address 3 C, j CJ 1 I— <br /> WAson <br /> �+5� (,p G S X05 Inspection Date <br /> Time In Time Out <br /> Business Rep TitleAM l e AM <br /> U QPM 0 PM <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 /> �J O 0 Active 0 Passenger ® Generator @ Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude ® Hauler Q Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use Container <br /> Business Type(Fill all that apply) <br /> 1 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX ) n <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance-No Violations o <br /> 0 1 0 1 Other:§ <br /> I z <br /> Comments (V_.1 (A CXA 1 ► `i` ' Y A N <br /> N(D vl4}ion_S 01 wkA5 <br /> Inspection Form Included: <br /> Comments Included: <br /> -- Bu ness Rep's Signature Phone Number Inspe is Signature one Number <br /> INSTRUCTIONS ON BACK Correct:4D Incorrect: 07q] E X A M E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink C y: ® ■ <br />