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Waste Tire Avey & Inspection Reporp Inspection Report Number <br /> Cal Recycle State of California <br /> CalRecycle 181(Rev.10/10) 1255846g��ey Form - Page 1 I1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 99 G( C� ` Inspection Type(Fill one) <br /> Site Suffix: t �� 9 6 �j 9 Q Routine ® Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �G�Cr U�qR CC�vV��� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical ddress C) 9, M A T7 <br /> PoC1,_ <br /> Vcz�V, C�\ 5Z-0 Inspection Date 6 <br /> Time In Time Out <br /> Business Rep Title ®AM Z O AM <br /> `� 9 d Q PM PM <br /> ,Nan ars <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 6 <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 2 � <br /> IS Active * Passenger S Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GP� Latitude Q Hauler 0 Indoor <br /> O Q Inactive a Truck <br /> Longitude — Q Planned • OTR Q End-Use ® Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government 0 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 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 EXT) 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 /> Uj <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 z <br /> ®In Compliance-No Violations o <br /> Q 1 Q 1 Other: <br /> Comments `�h5 2.0 �� ohA _S <br /> Inspection Form Included: <br /> 201 `i913 1 yt S �-`� ?-3Z k1 <br /> Comments Included: Uzi <br /> s' es p's Signature Phone Number Inspe0torlis Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: JE�XJA�MJPJL�Ej 1112 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />