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2 Waste Tire ey & Inspection RepoVInspection Report Number <br /> CalRecycle State of California I 1 - 1226293 <br /> CalRecycle 181iRev.10/10) <br /> (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 /> rTPID- Inspection Type(Fill one) <br /> Site Suffix: 1 3 � � �f '3 y U � 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 4yy, v4 1/4,9-t',v7 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Jrs <br /> l � 2 3 7- <br /> Inspection Date <br /> �� S Z 3 Time In Time Out <br /> Business Rep TitleO O AM O AM <br /> /J ® 0 ® PM © 3 8 O ® PM <br /> SGG�YCcL71LrY Ar"k S 11WN t - <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 /> S / 0 Active ® Passenger 0 Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> - — - ---- ---- -- - - -- -- 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 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 EX1) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> f <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 ®In Compliance-No Violations <br /> 0 0 Other:§ <br /> - - <br /> Comments / / <br /> t !�e� QiLtU/ ��j C��l�►�/YLg _ <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> Business Rep's Signature Phone Number nspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct-0 Incorrect: X E X A IP E 1 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Coy EA <br />