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Oa Waste Tire Survey & Inspection Report Inspection Report Number <br /> Cal Rec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey ®6' ll _ page 11 1242476 <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 p O o 1 Inspection Type(Fill one) <br /> Site Suffix: ` ( O 1 ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local r" If Referral,choose referral type(Fill one) <br /> Identifier. S a(� �Off{ LA_ rl 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name _11 b Inspected By Inspector <br /> r ?::, SV 0 <br /> Physical Address �S LU TT <br /> CA ( �SLOS Inspection Date CJ / 9 i <br /> cJl-fir, <br /> Time In Time Out <br /> 0 AM <br /> Business Rep Title 0 5 0 AM® PM L 5 ® PM <br /> 00(kn ,ef <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) C (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GFS Latitude 0 Hauler • Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 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 � Extension <br /> O O <br /> 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 EXT) N <br /> a <br /> in <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 9 In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments Z�__ <br /> U�A RRA <br /> 514 f)tA' \(A )fAS rO <br /> IQ <br /> No )J1Q (A_-_�U r+t QJ aA J tMA (_J L l) ,ern. <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> ® Busines p s Signature a Number Insp tor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: ® � E X A M P L E 11213 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop; ® ■ <br />