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Waste Tire S.-- rey & Inspection Report Inspection Report Number <br /> State of <br /> CalRecycle CalRecyclel181(Rev.10/10) <br /> Dept of Resources Recycling and Recovery(CalRecycle) Su rvey Form - Page 1 11 1210430 <br /> Part A-Survey ___BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- t � � � Inspection Type(Fill one) <br /> Site Suffix: 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: n pC1L► Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> C;kv� o� L�.�-1��o _ 1 <br /> Physical Addre 3 , Q 1 C-sCd`�1T <br /> 0 <br /> \- Inspection Date I <br /> CA q-5-SID t C <br /> Time In Time Out <br /> Business Rep Titlel 1- '�T• , S 0 AM 6 0 AM <br /> e�;1�yb d J�«e ufL,f7' d 0 PM o 0 PM <br /> � ►1,`C C�r1 p q LQ. Su r i'l�f,r�G�g�l1 --- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) r (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I& Active ® Passenger Is Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned 0 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet • 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 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 a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> r <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 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments Ai f0,,% [,(, G 0 <br /> No i��� 'c��5 0f ck}eus o+ c bf)-ce.rn- <br /> Inspection Form�nc <br /> ncluded: O <br /> Comments luded: A - l• <br /> Business gap's Signature Phone Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: �V EJXJAJ 1112131 <br /> 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy: EA ® 0 <br />