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® Waste Tire Su. Jey & Inspection Report Inspection Report Number <br /> CalRecycle State of California(Rev. <br /> 1196410 <br /> CalRecycle 181(Rev.10/10�y(cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 13 1 C) _ o Inspection Type(Fill one) <br /> Site Suffix: I* Routine Q Re-inspection Q Referral Q Observation <br /> Local �►" If Referral,choose referral type(Fill one) <br /> Identifier: SUn Q N �I Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> C f'zCx�zy Mu�V-;'A A"Al <br /> Physical Address 3 - l <br /> Inspection Date <br /> �5`vo(�Z"tco' <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 3o ® PM l S d 0P <br /> --- -- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger ® Generator ! Outdoor <br /> Q Closed Q Altered <br /> �P� Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned 40 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) pW <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 S 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 /> 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 /> 0 <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 /> 1 z <br /> Comments e- y1 105W A j' ,A CYC A�1� s /J1 i ( A <br /> QUI. � 1Vt.� W wtXe— 1�c� ' w�, A C <br /> , �Jl'_ <br /> - Nc, yio1� one of CA it" L&cpncAfn <br /> Inspection Form Included: Q <br /> Comments Included: r �7 O - •C �I <br /> gusines Rep's ignature Phone Number Insp is Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct:* Incorrect: X q E I X I A M L E I 1112131 <br /> 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pin 0 <br />