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0 2 Waste Tire S e & Inspection Repospection Report Number <br /> CalRecycle State of California Y <br /> - 1177961Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 <br /> Dept.of Resources Recycling and Recovery(calRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ( c-1 O f� _ Q Inspection Type(Fill one) <br /> Site Suffix: 1 ! f 41 Routine Q Re-inspection Q Referral Q Observation <br /> Local1 If Referral,choose referral type(Fill one) <br /> Identifier: S(', (',n'3 6M j t ,I n Wl \ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Ct�� �c,� <br /> o� n�'c un, (`P6_kft�v�in e�a�cz� 3 q - L� T <br /> Physical Ad ess '✓S (0 <br /> 6`(1 0 — <br /> Inspection Date / Q / <br /> nk�U cA q s 33'1 <br /> Time In Time Out <br /> Business Rep Title U O AM 1 1 O AM <br /> ) � 41 PM 3 + 5 0 PM <br /> AI�n Mon., . Phsksax>u� <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 /> Q Active Q Passenger Q Generator Q Outddo�or <br /> O $ Closed Q Altl/�reln N ( <br /> JA "1A <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q 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 Q Trucking Fleet 10 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 F 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 N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <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 Generatorsis In Compliance No Violations o <br /> Q Q Other:§ <br /> Comments <br /> No viols 'uns o) e,iteAs _ u� <br /> 0fip' ate*►eL1 �-o lab E - WA,,k-rri'0 Je, 5-k <br /> a. IkUI;k U �� TP D 1-7aZ 30 <br /> Inspection Form Included: Q �9 I { <br /> Bu ,� <br /> Comments Included: Q ✓� <br /> siness Rep's Signat e o e Number Ins tor's Signat a Phone Number <br /> INSTRUCTIONS ON BACK Corre Incorre X � qf E X M E 1 2 3 62081 <br /> t: . <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink I <br /> py: ® ■ <br />