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Waste Tire SuuuuuuuuRey & Inspection Report ispection Report Number <br /> CalRecycle State of CalRecyclelifornia 181(Rev.10/10) a Form m Page 1 I1 - 1242473 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey g <br /> BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- � � �•- a ,I Q � - O � Inspection Type(Fill one) <br /> Site Suffix: l "1 l ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: �ej>n 061, u1.1> Co Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Ali (a©a PG let 3 - (_0-rrb <br /> Physical Address 11 �L <br /> 1QS5 01' Ar�,UnU .7[ _ - - -- -- - - - <br /> c� Inspection Date / y <br /> ,J 10(_�Aor) C Sz b S Time In U Time Out <br /> /� ® AM ® AM <br /> Title <br /> Business Rep l �l p PM 5 0 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) •Active Q Passenger . Generator Q Outdoor <br /> -- 0 Closed Q N 1 <br /> GPS Latitude Truck d Q Hauler Q Indoor <br /> o Q Inactive <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) a <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 Q I <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other 11� l lQ� yl �cti�1 1^ <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 /> 6­6 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 it Vehicle m <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days --- a <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 <br /> 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 u]•,� G IIS ` ' vA "11� <br /> Inspection Form Included: Q VVV G 7-•70 <br /> Comments Included: in ss Rep's Si ure Phone Number Ins tor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Cect: Incorrect: g E X A M L E 1 2 3 <br /> orr <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy L <br />