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Waste Tire Survey & Inspection Report Inspection Report Number <br /> I:alRec cle State of California - 1242309 Y -CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 12 4 2 3 0 9 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- , a u Inspection Type(Fill one) <br /> Site Suffix. v� I V ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ^�OU�j iil l U'V Y_�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` Inspected By Inspector <br /> ( 4(o WW�a_',z .�ir— ( ter 3 9 - 1 O / C'S Cu'rTrJ <br /> Physical Address <br /> U e�wfiU� <br /> CA Inspection Date / U l 1 <br /> �Szl � <br /> Time In Time Out <br /> Business Rep Title ,1 d AM AM <br /> \, 0 PM � � ' � S � PM <br /> N v) l�o,n Sk ar�iS 0 r <br /> Operational Status Tire Type Business Role Storage Type <br /> i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) ` Q S <br /> Active • Passenger I* Generator �QOEutdoor <br /> C Q Closed Q Altered , <br /> GPS Latitude <br /> 0 Q Inactive Q Truck Q Hauler ® Indoor <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> • 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 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 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 M / m / m <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 EXE N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> N <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 /> Comments _k4 1 �,,,-� <br /> W tn�. 0c�l'e�1� <br /> Noy�olU��y�s 01 CA J( L_5 f C01)CiLrn- <br /> Inspection Form Included: -31 <br /> Comments Included: <br /> Ju iiu iness R p's Signature Phone Number %In, a tor's"Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X EJXJAJ 1 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop <br />