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2 Waste Tire SL. rey & Inspection Report , Inspection Report Number <br /> CalRecycle State of California 11 - 1230260 <br /> CalRecycle.181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Su_ryey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � O � -� � -7 - � 1 Inspection Type(Fill one) <br /> Site Suffix: It Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �Q h Teo j4 k�Y\ G5 V,n� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �-- -C �� ' -2q M T t ` <br /> Physics Address - C 1 ��J <br /> Inspection Date t ? / 1 S <br /> 1^ Time In Time Out <br /> Business Rep Title I �7 O AM O AM <br /> t /��,GCN'�l1tK`Cy L 0 PM V 46PM <br /> �" '-J G1\r ' •to —r" 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 O Passenger 0 Generator I' Outdoor i <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor 15' <br /> O Q Inactive 0 Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 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 ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation � Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q 0 PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> O O Other:§ <br /> Comments <br /> :w2 \k_ey S„ ��C'�y� �V\P cl>Y), 7-A-0-16AVS, <br /> _Ck & �NM.Q__ "\\6UZN_Ot )�5 <br /> h6 <br /> 4cv��> ak cm4eiz-ok <br /> Inspection Form Included: Q// <br /> Comments Included: <br /> ness eep's Signature hone Number Inspecto Signature Phone Number <br /> �,( <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X * NJ I EXAMPLE 1 11 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © 0 <br />