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- <br /> Waste Tire &.. ,fey & Inspection Repon, Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1177723 <br /> CalRecycle 181(Rev.10/10) 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- Inspection Type(Fill one) <br /> q <br /> Site Suffix: I r "l l © ® Routine Q Re-inspection Q Referral Q Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: SC.0 v. �� O CHP Q CalRecycle O Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> tA <br /> Physical Address O 7 1, `' °��L'LA <br /> Inspection Date �5 / c( / 1 <br /> Time In Time Out <br /> Business Rep Title O AM AM <br /> / I 1 7 0 PM � PM <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 /> 90 .®Active ® Passenger ® Generator Q Outdoor <br /> o Q Closed O Altered <br /> CaP� Latitude Q Hauler � Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned 0 OTR 0 End-Use 0 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 &.4, YL F&n'atncc_ <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E)C7) N <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement s <br /> LU <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 19 In Compliance-No Violations o <br /> Q 1 O 1Other:§ <br /> Comments ` <br /> V <br /> Inspection Form Included: Q �' /` <br /> Comments Included: ® ZLI -SrL9 ;PBusiness Rep's Signature Phone Number s e ature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: I EJAJJLJEJ 111213 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: EA <br />