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Oa Waste Tire Sull Jey & Inspection Report inspection Report Number <br /> CalRecycle Cte of aaRecyclelifornia 181(Rev.10/10) 11 - 1210227 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Su rvey 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: ( 0 � 6 0 l 40 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �� � �� � If Referral,choose referral type(Fill one) <br /> Identifier. 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> PcIr-M L-AL- , <br /> Physical Address 9- riZ!3 0 L <br /> J Inspection Date •7 <br /> / <br /> Time In Time Out <br /> BusinRss Rep F Title 0 AM 0 AM <br /> r(JCtiYYI C �Ccr� ►�� 3 ® PM Z 'V PM <br /> �� �-�.p•� bwirt�>� <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 /> ' l 0 Active is Passenger . Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude ® Hauler Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude 0 Planned 0 OTR 116 End-Use ® Container <br /> Business Type(Fill all that apply) <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 (a Hauler 0 Agriculture 0 Shredder 0 Other A o6k-r- ilAvww— kheCM,/Ajt,�,{b,)h rrr <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 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires ®Notice Of Violation Extension <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 <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle ` It <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <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 /> 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 0 In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments - <br /> Se� C�rnrrt�r�,13 <br /> d <br /> Inspection Form Included: <br /> Comments Included: ® I 1o't- pe <br /> 73 <br /> Business Rep's Signature Phone Numberp t s pfonature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:0 Incorrect: EJX AIMI PI LJEJ 11 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />