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0 Waste Tire SA & Inspection Repopection Report Number <br /> CalRecycle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1242214 <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 _ Inspection Type(Fill one) <br /> Site Suffix: 4& Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: J�,rt �/j��iG[.iiy 0 CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address V 3 - / Q X3 Q 0 /!/j-4 01-,,4 <br /> .2,;. 3 5 1ti' �r— vc <br /> S-4a4j4o, 95_0�Os Inspection Date D 7 n- ( / ! z1 <br /> eX ` <br /> Time In Time Out <br /> Business Rep Title f � � (/� AM f � �~ AM <br /> � <br /> / !� Q PM QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 300 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active ® Passenger • Generator Q Outdoor <br /> Q Closed O Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use • 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 ® 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 /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> O Q Other:§ / <br /> Comments a Iry�"�' ^L � G7Rr� a-ze.,e -/4c <br /> /�/'��cr-vp«J.�' �16��-ox //n/�/3� ��r� /��-arc �-."^ry e��-i �. �r �}[-/�•:���.� �/� ;,r``�j°..ey,�, " <br /> l/�`2�.�c,0 ��✓! /�c�'.c.��yr- �' ck, ,r�• r� t�`�� � �f�e�f. /�'i lf��R�_Oyj 1 <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business ep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � � E X A M a E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink C :L <br />