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Waste Tire Su, Bey & Inspection Repon Inspection Report Number <br /> CalRecycle State of California <br /> - 1210305CalRecycle 181(Rev.10/10) 01 AMS� �/J ®�^YH _ ����A 11 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) 6�!!�J9 G �Y �J 1'1 Page <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` Z - 1 Inspection Type(Fill one) <br /> Site Suffix: 1 1 d ` !Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ,^ �3'0 y —t r CovAk�I� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> TO S Go--,e � - I o nfi T v <br /> Physical Address <br /> 3 70 e_ <br /> � `�533a Inspection Date / 2 <br /> La „co e C <br /> Time In Time Out <br /> Business Rep Title O AM G O AM <br /> ��2���'n S �i 1 ` �� L O PM J O PM <br /> C' -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) d kA <br /> 1� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> _1 40 Active 0 Passenger ® Generator 0 Outdoor <br /> GPS Latitude 0 Closed 0 Altered <br /> Hauler 0 Indoor <br /> O 0 Inactive @ Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 0 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 HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 <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 <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 14 CCR§18460.2-Manifest System.Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> LU <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 /> 0 0 Other:§ <br /> Comments <br /> Inspection Form Included: t , <br /> e ✓L/ 1 /� ,� <br /> Comments Included: � 1 ( - <br /> Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: IEIXIAIMIPILIEI 1112n3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />