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0 0 Waste Tire Mey & Inspection RepApinspection Report Number ■ <br /> CalRecycle State of California — <br /> CalRecycle 161(Rev.10/10) Survey Form - Page 1 11 1210282 <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 Type(Fill one) <br /> Site Suffix: L <br /> ( C, 5 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local \ If Referral,choose referral type(Fill one) <br /> Identifier: _Sav, ,� �� //V1 i Q CHP Q CalRecycle 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address - 1 Ane,UL4 <br /> ! `,� /� Inspection Date <br /> 1 � lEi�J LH Q533C Fy <br /> Time In Time Out <br /> Business Rep Title j p ® AM ®AM <br /> [ 1 ' oZ V QPM , S QPM <br /> �it�S t ei �ICA/Cl✓ `fT <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 Q Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR 0 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 Q Crumb Rubber <br /> Q Service Station 0 Hauler Q 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 /> 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 /> 00 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 0 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 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> Inspection Form Included: Q ' <br /> i Comments Included: ® <br /> Business Rep's Signature Phone Number Irlipictor'iSig6ature, Phone Number <br /> INSTRUCTIONS ON BACK <br /> Correct: Incorrect: NJ E A M L111 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop L ® ■ <br />