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Waste Tire Su, vey & Inspection Repon Inspection Report Number <br /> C81Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10). Suf'1/e� Form - Page 1 11 1230384 <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� � - � � Inspection Type(Fill one) <br /> Site Suffix: , 7 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier �Qh �(jQQ e9`\1� Co V h Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name —V Inspected By Inspector <br /> Physical Addrs 3 1 l� MA I-TU <br /> LA <br /> Inspection Date <br /> 05 /1 <br /> Time In o Time Out <br /> Business Rep Title AM I AM <br /> I Q PM Z I O PM <br /> G10 �vn `�:kvS C�w -C' <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I f Active Q Passenger ` Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 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 /> 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 40 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> N <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 /> 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.- � Ch ul&AS t �M-Te '�CO2 tJhwO �w.r. �v� .�C 40—J&=CA N <br /> 1 <br /> '4N <br /> Inspection Form Included: Qr,1/Q�-? b l� <br /> Comments Included: s `LPh a um <br /> Business Rep's Signature Phone Number Inspec or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />