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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRec cle State of California - 1230293 Y calRecycle181(Rev.10/10) Vurvey Form - Page 1 I1 12 3 0 2 9 3 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 5 O � Q _ y� inspection Type(Fill one) <br /> Site Suffix: O (J ® Routine Q Re-inspection Q Referral Q Observation <br /> Local [ If Referral,choose referral type(Fill one) <br /> Identifier: Ju�1�0�1�U1��1 tAnQ CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �N r-C-N S AA? Cd�P�-,�, LLL 3 <br /> Physical Address <br /> LAJ V_ <br /> ,\ Inspection Date / 3 / 1 5 <br /> Time In Time Out <br /> Business Rep Title O AM e O AM <br /> .{ v ® PM J S is PM <br /> �O � LC V C.S 1 k�Ic� vic.n Mit. <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 Q Passenger 0 Generator Q_Outdoor <br /> 0 Y�Q1 <br /> GPS Latitude _ Q Closed Q Altered J <br /> Q Hauler Q Indoor <br /> o Q Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 0 Other p�s� � o f " <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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <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 o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> La <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 0 In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> Comments 0-0AINA- V'. 57t�ji la.. ins, �o-\ a 13AQ U tnok )y L !An +i1ne <br /> l <br /> �I`JO V�oIX. )X%S 0/' (kr[ V.0 of Gb ern <br /> Inspection Form Included: <br /> ;Busines4 <br /> Comments Included: ACRe Signature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS Correct:0 Incorrect: E X A M P L E 11213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co : ® 0 <br />