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Inspection Repo"Inspection Report Number <br /> � Oa Waste Tire urvey & Insp p � <br /> CalRecycle State of California <br /> CalRecycle 181(Rev.10/10) 11 - 1176748 <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A-Survrey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> f� <br /> Site Suffix: a[ C l I I ® Routine Q Re-inspection Q Referral Q Observation <br /> Localn If Referral,choose referral type(Fill one) <br /> Identifier: ��n�o � Q1Af� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> I O <br /> (' Inspection Date 10 <br /> (� <br /> 1 ` � 6k Ae-c� ` A R " �y/-� Time In Time Out <br /> Business Rep Title 0 O APA ^ � Q 0 AM <br /> `J O PM t71 ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> d J] <br /> PS Latitude 0 Closed Q Alt�J l� Q HaulerR 1r1 Q Indoo�A <br /> G <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 /> 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 ®+Other s��C9 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 Q 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 <br /> (Required for NOV or EX <br /> Q Q 7 <br /> N <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 /> w <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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 /6N, 08 r <br /> \w 1 <br /> S1 C - <br /> �1 c� Ui� a ions S s s (a n- <br /> N --on— <br /> Inspection <br /> -onInspection Form Included: Q <br /> Comments Included: — <br /> _Q'Business Rep's Signature Phone Number Vlp is Signature -Pone Number <br /> p - <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: �, � E X A M L 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop © ■ <br />