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Inspection Report Number <br />Waste Tire Su. vey &Inspection Report� <br />State of <br />CalRecycle CalRecyclel'fornia 181 (Rev. 10/10) <br />Dept. of Resources Recycling and Recovery (CalRecycle) Survey Form — Page 1 11 1242496 <br />Part A - Survev BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPID -I 5 M <br />Site Suffix: <br />Inspection Type (Fill one) <br />V <br />0 Routine Q Re -inspection Q Referral Q Observation <br />Referral, choose referral type (Fill one) <br />LocalIf <br />Identifier: S �1 Cl -TCCA "1 CU1AA <br />LAI <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Business or Facility Name <br />�c��s3 <br />Inspected By Inspector <br />mCa5+�a- <br />ress <br />tPhysical <br />L Q l e s TOTTO <br />a- Own- 11 <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />)Iis�� <br />Inspection Date /I '7S/ <br />4 <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Time In Time Out <br />Business Rep Title <br />AM 40 AM <br />c <br />1 1 . 1 5 1 J <br />\ <br />erne TV J oroke&,n efOAAJQ, I'O, 'b1 f. <br />O PM ` 1 Q PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Q <br />Tire Count (Whole/PTE) <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />Q <br />0 Active <br />Q Closed <br />a Passenger <br />Q Altered <br />® Generator <br />Q Hauler <br />If Outdoor <br />Q Indoor <br />GPS Latitude <br />O <br />Q Inactive <br />® Truck <br />Longitude - <br />Q Planned <br />® OTR <br />Q End -Use <br />Q 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 e Other (br11;re C1 fO LOIA-T&C,6jtr <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q <br />Q <br />Other: § <br />Comments aov <br />R <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EX7) <br />Q Referred / CalRecycle Enforcement <br />IS In Compliance - No Violations <br />Inspection Form Included: U— <br />� \ � '{� S -o�9b Lug l�lrrz4--3)'7 � <br />Comments Included: ®-� <br />Business Rep's Signature Phone Number Ins tor's Signature Phone Number <br />INSTRUCTIONS ON BACK [Correct: 0 Incorrect: E X A JL11213 62081 <br />■ White Copy: CalRecycle Yellow Copy: Operator Pink Co T ® ■ <br />N <br />0 <br />i <br />f <br />w <br />0 <br />z <br />