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® Waste Tire Si lley & Inspection Repor" Inspection Report Number ■ <br /> State of California <br /> CalRecycle I 1 - 1177598 <br /> CalRecycle 181(Rev.10/10) <br /> (Cal 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- q t Inspection Type(Fill one) <br /> Q <br /> Site Suffix: ' 7 d -1 l f 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: IA �0t:Cqy%y� �0yvv� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name L 0 1 Inspected By Inspector <br /> a Q cA l` y tree W`n 2F L ` <br /> Physical Address I <br /> 2S 37 \J�Ne 0o ��.. <br /> �� US Inspection Date ­7 3 <br /> S�OG��OY� Time In L Time OutC <br /> Business Rep Title 0 AM O AM <br /> (— I ' : -3 O O PM -3 SPM <br /> - - - - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 20 <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ® Active • Passenger ® Generator a Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® 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 /> _1 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 Q § - ®Notice Of Violation Q Extension <br /> PRC 42951 Waste Tire Hauler Registration and Transport of Tires <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 014 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date Mt A MC!)2 / M <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 EXn N <br /> a <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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance-No Violations o <br /> Q Q1 Other:§ <br /> + \ it <br /> Comments �Lcv <br /> Al_a,v-e_ Q )a:b <br /> 0.1 <br /> See Co►�w�e��S ��-S� - — <br /> Inspection Form Included: Q <br /> Comments Included: b -703 ZOl-146$- 3zlz <br /> Business Rep's Signature Phone Number Inspec or's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: IEIXIAIMIPILIEI 111213] 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © 0 <br />