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Waste Tire .survey & Inspection Report Inspection Report Number <br /> - State of California <br /> CalRecycleT 1 <br /> CalRecycle181(Rev.10/10) �IW�/ey ®riPi m ���e °� 11 1242215 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) S � 1/ 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> _ <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: ( C1 __7 L 0 ( ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: _S(','Y\. �)OG`'C U�� Ce'L4,u Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name / Inspected By Inspector <br /> -F4-I: ,�(C'✓ Pry Z_ 1� <br /> Physical Address l o A ` 1 rne7 i A <br /> n lJ� <br /> 10,Y t - <br /> Inspection Date -7 <br /> Time In Time Out <br /> Business Rep Title ® AM ® AM <br /> © U S O PM / 0 Z S O 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 /> ' Q Active Q Passenger all Generator Q Outdoors <br /> GPS Latitude O If Closed Q Altered/4 Q Hauler Q indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 O 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 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 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 N <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 /> 2 <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 1 Q 1 Other:§ <br /> Comments �I 1� �M K <br /> w / ry� <br /> Il Iv &�L 44is c a v6 Ic ;/7,w-,) /Ia/tc� <br /> i i 6 L <br /> AV �?Z,-7 6o � r`1�` Le-.,o ✓r Ln to <br /> Inspection Form Included: O <br /> Comments Included: O <br /> Business Rep's Signature Phone Number In p tor' na re Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A P 11213 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink C ® ■ <br />