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2 Waste Tire S&ey & Inspection Repor, inspection Report Number <br /> CalRecycle State of California 11 - 1226286 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <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 <br /> / .S J j - O Inspection Type(Fill one) <br /> Site Suffix: / (� (o ® Routine Q Re-inspection Q Referral Q Observation <br /> Localr'"1 If Referral,choose referral type(Fill one) <br /> Identifier: <&60 yu 6_ •-.�L.� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name "�"�J Inspected By Inspector <br /> ` <br /> Physical Address <br /> 4 Inspection Date / l / ! 17 <br /> Time In Time Out <br /> Business Rep Title 0 AM 1 0 AM <br /> PM O I S U ® PM <br /> J J 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 /> ® Active ® Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <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 ® 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 I ENFORCEMENT STATUS <br /> r -- - <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 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 <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 /> 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 Other: <br /> Comments <br /> �(1y},�YILI/ /�/?< C.y✓ ��f�."S' �G- 'Y� �DlC�il.�-�/Yt-t ,� <br /> Inspection Form Included: O, ' I <br /> 3 <br /> Comments Included: <br /> Business Rep'sqSigna P e Number inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Corre Incor eCt: E X A M L 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L <br />