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R o*nspection Report Number <br /> � Waste Tire S ey & Inspection ep <br /> cle State of California <br /> CalRecycle _ <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1255787 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- l Inspection Type(Fill one) <br /> Site Suffix: �1 1 t./ 9 Routine Q Re-inspection Q Referral Q Observation <br /> Local ' If Referral,choose referral type(Fill one) <br /> Identifier: '�1 {�1 �QC'C !f l y 7 C c'a-L, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address ✓I,, / �� f �tlyt��, �� `�� <br /> Inspection Date <br /> cif <br /> Time In Time Out <br /> Business Rep Titley ® ,3 0 AM 0 AM <br /> L ' f PM -3 ® PM <br /> Ilia Yn_ <br /> perational 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 /> (� 0 Active 0 Passenger ® Generator 41 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — Q Planned • OTR 0 End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair • 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 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 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 m / m <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 EXT) n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <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 O In Compliance-No Violations o <br /> Q Q Other:§ <br /> :.yL(�LY,f GC rc AT, GC� <br /> Comments L ..i L��1�.� �i� �.�G-C f:� lrt I LL(!� (�Gtz� ee.,J <br /> 1. <br /> l//C>C G d 6. cy�_ C`Y L�%ls� �l/'— . �'/� C Ciy f_Ij .-Al <br /> Inspection Form Included: Q )� <br /> Comments Included:0 <br /> Business Rep's Signature Phone Number Inspector's Sig Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EjXjAjMjPjLjEj 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />