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Oa Waste Tire Skey & Inspection Report Inspection Report Number <br /> CalRec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1177560 <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 J _ Inspection Type(Fill one) <br /> Site Suffix: !) l S � © I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local {-, If Referral,choose referral type(Fill one) <br /> Identifier: aCa �� C �'�' `� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l Inspected By Inspector <br /> Q JC'�'sI T � -) 9 <br /> Physical Address <br /> 00-7 W. 1v>ern Fr__ Avc., <br /> Inspection Date n <br /> t�vl�&� C/a q5�"S`7 <br /> 5 C> l <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> �1SEe r ivy 1-k'v t� `1 -2- ' U f/ ® PM l IV 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 /> Q Active QPas enger ® Generator Q Ou door <br /> A <br /> Latitude O �Closed Q Altered �� <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q 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 /> ® 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 <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments•g <br /> avt Ail, <br /> 1i7,�rT rf� OicitU L�JkG s $ �^ 1 t '- <br /> -fin►3 ��1�• �i c c o�rr,rrlr�n `'(1 �- 1'�s 3�� bG e-7 cD <br /> Inspection Form Included: Q , <br /> Comments Included: <br /> V ' 23 Z7 `Z 20-7 �F15 <br /> uslness Rep's Signature Phone Number I p cto s Si atyre Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EXAM E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />