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rinspection Report Number <br /> Waste Tire S�,. trey & Inspection Report <br /> CalRecucle State of California <br /> J CalRecycle 181(Rev.10/10) Surrey Fora ® Pale 1 1 1196434 <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 Type(Fill one) <br /> Site Suffix: CZ 6 s Site Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. � �`�� ©V� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> O\ (( ACI, l(OLA)v1 _ <br /> Physical Address <br /> o2t5o Z , VVLPi✓ . <br /> Inspection Date ,? / ® / l 3 <br /> C�A <br /> Time In Time Out <br /> Business Rep Title �7 O AM O AM <br /> C;?'_ ®PM C� � C 0 PM <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 /> IQ Active 40 Passenger ®Generator 46 Outdoor <br /> O Q Closed Q Altered <br /> G�� 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 /> 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 ® 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 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 N <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 Q1 Othbr:§ <br /> - z <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: y6 3 <br /> Business Rep' ignature Phone Number I p or's Ign re Phone Number <br /> INSTRUCTIONS ON BACK Correct4 Incorrect: XA � rJ E A E 12 3 62081 <br /> zX■ White Copy:CalRecycle Yellow Copy:Operator Pink Co y: ® ■ <br />