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Waste Tire SL.. Bey & Inspection Report Inspection Report Number <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 1196291 <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 /> Site Suffix: 6 Ip 6 G l ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalL If Referral,choose referral type(Fill one) <br /> Identifier: ��v� v-A1"-, LCILM.I 1..� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I Inspected By Inspector <br /> U- V s S 3 - 1 0 ( l ►ltm <br /> Physical Address <br /> -7701 0 .S bran, 9�,►� <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Tale l ✓ 0 AM } 0 AM <br /> CEJ M &9, �G J <br /> of PM ;� { S ® PM <br /> r ! Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) y (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 10 Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> CIPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q 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 () - t-6t \ <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I 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 /> PRC§42956-Registration/Decal in Vehicle <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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXn N <br /> a <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 /> 2 <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 /> _ z <br /> Comments ` <br /> Inspection FormIncluded: Q <br /> Comments Included: <br /> Busi ss Rep's Signature Phone Number IspqEt Si nature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: E L E 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop •L ® ■ <br />