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� Waste Tire"Sley Inspection Re& ins "nspection Report Number <br /> � p <br /> CalRecycle State of California I 1 - 1176394 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> N <br /> Part A-Survey - <br /> Business Profile Inspection Details <br /> TPID- Inspection Inspection Type(Fill one) <br /> Site Suffix: 1 O` * Routine Q Re-inspection Q Referral Q Observation <br /> Local \ ( � If Referral,choose referral type(Fill one) <br /> Identifier: so,n�00 v n l�C UfA Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> U 054_1-0 PN�\��C_ �(cW_)'�Z_ S C)f,0oo <br /> Physical Address 1 &0 <br /> \ Inspection Date <br /> Time In Time Out <br /> Title 9 AM AM <br /> Business Rep O PM Q QPM <br /> Cv.r� Yosz- <br /> C61¢G�t1�n�L <br /> -- 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) C 3 <br /> ® Active Q Passenger � Generator � Outdoor <br /> C Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> C Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 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 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m m N <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CC (Required for NOV or EXE — N <br /> R§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 /> 2 <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _._.— <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ 11 1 ] �. <br /> Comments 9 c� c7SfnQ,r/� bf>�1�1 A�1-e- w L 4 <br /> '�l�L�2��(�. GAS ���-J''• - <br /> Inspection Form Included: Q <br /> Comments Included: ® Business ep's Signature Phone Number Insp&e%nature 1 (Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: NA ("V) NJ E X A P L 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L © ■ <br /> ■ <br />