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Waste TirMrvey & Inspection Rep't L Inspection Report Number <br /> State of <br /> CalRecycle CalRecyclellia 181n(Rev.10/10) T 1 — • <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 1 1 1177510 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` r O _ /� Inspection Type(Fill one) <br /> Site Suffix: I 7 I �J ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �-- jIf Referral,choose referral type(Fill one) <br /> Identifier: �fl JOCA- 1A1I ) (01/�,{lQ CHP Q CalRecycleQ Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address ��' �.� C Sc a7 T 0 <br /> S <br /> � � <br /> Inspection Date `A�iS3Zo <br /> Time In Time Out <br /> Business Rep Title p 11 G /D l AM AM <br /> Lu(e. V11Ge \J��]�{)1 1 �J V 0 P I I V OPM <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 40 Passenger I& Generator If Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude — Q Planned 4j 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 I* 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 /> 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 /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE 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 ®In Compliance-No Violations o <br /> Q Q Other:§ y <br /> Comments �i T� 1r� ' �u� d 3 JurC (inl I e- N <br /> ko <br /> 00 ylda V3 VJ a/JCOS J+ M)Cefj) <br /> Inspection Form Included: Q G t� <br /> 'lAlo- <br /> Comments Included: <br /> ,� ��Insctor's <br /> 4, �Q I ���_�� / <br /> Busi ess Signature Phone Numbature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EXAM E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pin opt.LEA <br />