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03 Waste Tire Su. Bey & Inspection Report Inspection Report Number <br /> CalRec cle state of California <br /> Y CalRecycle 181(Rev.10/10) Survey ®rm - Page 1 11 - 1210395 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLU_ E OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� � � � � � 1 Inspection Type(Fill one) <br /> Site Suffix: l o Routine 0 Re-inspection 0 Referral 0 Observation <br /> Localn If Referral,choose referral type(Fill one) <br /> Identifier: Sd J o CLI 01y., (510 • 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name f Inspected By Inspector <br /> Physical Address 0 "4 <br /> / ATTU <br /> � <br /> Inspection Date <br /> J�'loL�iT2r �� GIS33� <br /> Time In Time Out <br /> Business Rep Title O AM I (, O AM <br /> ,�-1 M0.tkg <br /> Owner <br /> 0 PM � v 0 PM <br /> - - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 2 d (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 10 Active 0 Passenger 10 Generator is Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer • Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> O 0 Notice Of Violation 0 Extension <br /> O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m m / Ffl <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX77 n <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <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 /> O 0 Other:§ <br /> Comments n n <br /> t s� - S Pec ►��.� a vt + S cx�c. ? c �dl <br /> elf <br /> �o v sol � Cot�cp r+� <br /> Inspection Form Included: 0 (14y" <br /> Comments Included: <br /> ?�1-q6$--3Z84 <br /> Busin s Rep's Slignature Phone Number Insp ctor's Signature Phone Number <br /> INSTRUCTIONS ON BA K jCorrect:0 Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />