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0 Waste Tire Soe & Inspection Reporp Inspection Report Number <br /> CalRecycle State of California Y p <br /> CalRecycle 181(Rev.10/10) Survey Form Page 1 I1 1245225 <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 Inspection Type(Fill one) <br /> Site Suffix: I 3y ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Adyess <br /> 166 Cn�v_ <br /> /,(t Inspection Date 6 / 03 <br /> / <br /> Time In Time Out <br /> Business Rep Title �J c O AM 2 O AM <br /> ?� �'C�- C� L - J I `PM <br /> PM / O <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 /> 7 * Active Q Passenger &Generator • Outdoor <br /> o Q Closed Q Altered <br /> ��� Latitude Q Hauler 0 Indoor <br /> O Q Inactive 40 Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair I* 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 Q 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 /> 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 /> Q Q 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 EX7) N <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 /> 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 Q1 Other:§ <br /> CommentsN <br /> A 36�0 C4 k2n� C�k C04NQM <br /> Inspection Form Included: Q L1, <br /> Comments Included: , pect b7 <br /> Business Rep's Signature Phone Number Insis Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: X IEIXIAIMIPILIEI 11 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />