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Waste Tire y & Inspection Re of Report Number ■ <br /> CalRecycle State of California 11 - 11716404 <br /> CalRecycle 181(Rev.10/10) <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE <br /> Form - Page 1 BLUE OR BLACK INK PEN <br /> Part-A-Survey — - <br /> Business Profile Inspection Details <br /> TPID- <br /> Inspection Type(Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalJ If Referral,choose referral type(Fill one) <br /> Identifier: OtA,�LA <br /> jr,\ 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name inspected By Inspector <br /> Ic-',\ C, <br /> - � 0 1 �c� EPhysical Addressc4o <br /> Inspection Date 7 / .1 / I <br /> `A0 Time In Time Out <br /> Business Rep Title a AM AM <br /> 0 PMV 0 PM <br /> C, C Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) ® Active 0 Passenger Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> 0 Hauler 0 Indoor <br /> GPS Latitude 0 0 inactive I* Truck <br /> Longitude 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> —0 New Tire Dealer 0 Auto Repair 9 Trucking leet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 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 FacilityEN�FOORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadifine <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M M <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EX7 <br /> C? <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred CalRecycle Enforcement <br /> 2 <br /> w0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities — <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations <br /> 0 0 Other:§ <br /> Comments (vntA <br /> Oxcl rnA fv 1-1c) <br /> -)0 <br /> Inspection Form Included: <br /> Comments Included: 0i Business Rep's Signal ure —Ph-,n,—Number Ins�p,, r",Signature --Phone Number <br /> 62081 <br /> [Correct: <br /> INSTRUCTIONS ON BACK * Incorrect: Vl�e< E X A L 2 3 <br /> Pink C y:L <br /> ■ <br /> White Copy:CalRecycle Yellow Copy:operator qVI © ■ <br /> M <br />