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0 Waste Tire SL. vey (R-A, Mspsctt c ll Repon. Inspection Report Number ■ <br /> CalRecycle State of California 1 e 1242284 <br /> CalRecycle 181(Rev.10/10) a l��/ c��J ��P?fifl ���l <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey�J !1 IJ� 1 a g <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: I 6 l 1 (� Q l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ��� i 0��� � If Referral,choose referral type(Fill one) <br /> Identifier: J Ovy%'�L, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name -Ta �t__ S Inspected By Inspector <br /> LUQ,, /,1c�vl lZ,, jP6A Fo4e� 3 � - l U l A P�� M ISL 1-lq <br /> Physical Address <br /> fInspection Date / 0 <br /> �S��U Time In Time Out <br /> Business Rep Title AM ®'AM <br /> I t ' C2 D QPM I S S QPM <br /> Lv r3 <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 /> ® Active 0 Passenger Q Generator Outdoor <br /> O Q Closed Q Altered <br /> G�S Latitude ® Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use a 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 f i <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other ► `db t l'(- i 1Y'Q- Sc'lr's <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 /> 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 EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <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 Q Other:§ <br /> z <br /> Comments ` <br /> Cow Molls C�w <br /> Inspection Form Included: O ZCIP '_�w _Iry(l <br /> --iDS 67 <br /> Comments Included: <br /> -- Business Rep's Signature Phone Number 41sp4tor4's,&ig�Oatune Phone Number <br /> INSTRUC]ONS ON BACK Correct:0 Incorrect: E X A 111213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C p :L ® ■ <br />