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41 <br /> Waste Tire SO y & Inspection Reporowspection Report Number <br /> cle State of California <br /> CalRecycle - 1245087 Y CalRecycle 181(Rev.10/10) urve� ®rrn o Page 1 I1 12 4 5 0 8 7 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- , p _ Q ( Inspection Type(Fill one) <br /> Site Suffix: v� t-r 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalC n If Referral,choose referral type(Fill one) <br /> Identifier: L.r cap 0 v 0 l C,Lt' Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> i �Inspection Date Z <br /> ��v Z Time In Time Out <br /> Business Rep /,,I -X Title O AM j O AM <br /> L k(QYLriI rte- 1 ® PM !r 5® PM <br /> ��/ �'�✓Vlc�� �/1C1��y�iv <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only). (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto�6 d� Q Car Dealer Q Collection Q Crumb Rubber ^'� <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other 1 VCe�C� ���,��, . <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 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 <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 EXE N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <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 a In Compliance-No Violations o <br /> Q Q1 Other:§ <br /> Comments FU_6N,.� ✓r(�`dn / I�i.2� j h t./72 C4.-- <br /> Inspection <br /> Inspection Form Included: Q • y �7 <br /> Comments Included: <br /> usiness Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: � NJ IFEFXIAIMIPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />