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Inspection Repoli Number <br /> Waste Tire & my & Inspection Repor, � <br /> State of California <br /> CalRecycle <br /> CalRecycle 181(Rev.10/10) Survey Fora gage 1 I 1 1178036 <br /> Recycle) <br /> Dept.of Resources Recycling and Recovery(Cal <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 41 Inspection Type(Fill one) <br /> Site Suffix: `j 5 1 1 ©' ( (j§ Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SGt n ��c``�.nh GOtJ�1. Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - l( Inspected By Inspector <br /> D"CtiVVI ONAC—, <br /> Physical Address 3 9 / t <br /> A,m, bL,l,,� <br /> Inspection Date Zor <br /> 'I've Out <br /> 6 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> I Z 40 PM ® PM <br /> I Z Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 41 ® Active Q Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned 0 OTR Q 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 0 Other -�- �i h�'�►��+t c_/t�r� <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 /> 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 " <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q ® 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <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 <br /> In Compliance-No Violations o <br /> Q Q 1 Other:§ <br /> Comments <br /> Inspection Form Included: V <br /> Qg 3„y qo <br /> �—Comments Included. ( 7 <br /> iness Rep s 'gna re Phone umber In a tor' I at y fe Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: JEJXJAJ1 111213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co y:L ® ■ <br />