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Waste Tire Sley & Inspection ReporLslnspection Report Number <br /> State of ornia <br /> CalRecycle CalRecycle 1181{Rev.10/10) — <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 -- I 1 1229974 <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � I Inspection Type(Fill one) <br /> Site Suffix: 1 O Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �� \ If Referral,choose referral type(Fill one) <br /> Identifier: ��� J C'r. �j�Y\ V�'h/ 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> Physical Address � �" 3q - lo 7 3 <br /> Inspection Date 0 <br /> Time In Time Out <br /> Business Rep Tittle^ — 0 AM 0 AM <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 /> /(2 1&Active 0 Passenger _0 Generator 0 AO1utdoor <br /> O 0 Closed 0 Altered )QA <br /> A <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Other IJ�J�s A— � ir& SV��1' �S <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7 N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments rn �. Any-,e o y-\ Q <br /> C We- <br /> e- Y\ <br /> Gus C0r\c_ V <br /> Inspection Form Included: 0 ZO !3/' 2yo7 <br /> �— �- 26C <br /> Comments Included: S <br /> Business Rep's Signature Phone Number Inspectds Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A M P L E 1 3 62081 <br /> 2 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />