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Waste Tire SL.-,iey & Inspection Report Inspection Report Number <br /> CalRec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Su e ®rte _ Page 11 - 1177981 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 1 6 156 6 R U l (0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Localc . � , <br /> If Referral,choose referral type(Fill one) <br /> Identifier: 'Sck -zl"" 4D'_ h-j 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> 0 Lt i ­F4-et,ns P <br /> Physical Address v Zyi��C1 <br /> Inspection Date -7 Z_ <br /> Jul -i„�-� C� c�5a1p S <br /> Time In Time Out <br /> Business Rep Title AM &AM <br /> // t'Ev+'l¢'✓_jI�.'�,�iY`' a P ( c� Z J 0 PM 10 �'f !✓ 0 PM <br /> 4LY�U L7c -NyY1� f<cJc✓�� �j J 7-&-e-1 <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) �f (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> - 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> Latitude O ® Closed 0 Altered O Hauler �A//It <br /> GPS <br /> 0 0 Inactive ®Truck <br /> Indoor <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 ® Trucking Fleet 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 Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> a <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> W <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments <br /> c 111,A <br /> c <br /> Inspection Form Included: <br /> Comments Included. 9` S�i< a 7 g6 <br /> Business R s Signature Phone Number I p o S' nature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A L E 1 : 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: ® 0 <br />