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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of <br /> CalRecycle CalRecycle1ifornia 181(Rev.10110) I1 - 1226690 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form — Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 1 3 3 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalC-. 1 (' If Referral,choose referral type(Fill one) <br /> Identifier: CA J U al U I,1-\ "�t��1 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name L Inspected By Inspector <br /> 0 ' <br /> C(9 Af)tr Lo()vAf <br /> Physical Address � °f - ( U I 63« EU <br /> 3�toD �ti�nor V <br /> Inspection Date � I � Q 0( J � I <br /> �J CA `lSw9 <br /> Time In Time Out <br /> Business Rep Title { O ®AM \ 0 AM <br /> ST(' �Gll11C, QPM V V QPM <br /> P U S Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger ® Generator ® Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) Coli <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other a-10" al (011nt1.4411 <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 PR0 Notice Of Violation 0 Extension <br /> C§ -42951 Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> Lu <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators (a In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments �.a_ lily w4c. +4, ',n5p,.JI0' Joa on iVI, 14h ULI (JIV n q <br /> fela vilo(AL-ns as uLci&&--a� co ((Axn <br /> Inspection Form Included: 0 <br /> mens Included: <br /> Com t ® B ine Reps na Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* ncorrect: XJ� q E X A M P L I E1,4112 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L © ■ <br />