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Waste TirAlRe & Inspection Re uribinspection Report Number <br /> CalRecycle y p p _ <br /> State of California <br /> calRecycle181(Rev.10/10) Survey Form - Page 1 1 1242447 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � �y � � � _ O 1 Inspection Type(Fill one) <br /> Site Suffix: "� 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �aovZr coVw Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> � ?333 Cow�cov�uc �. - <br /> Inspection Date C> 7 ' <br /> M oan�e csx_ C�c �533� <br /> Time In Time Out <br /> Business Rep TitleL O AM � : � C) O AM <br /> L <br /> o �PM 0 PM <br /> �a�o �wv` Owv�2f <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 /> Q Active QP�sepger Q Generator Qout c�Oor <br /> Q <br /> O 0 Closed Altered `��AACC / <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q 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 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 <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 <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 <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 E)C7) 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 In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments�OUk` <br /> kftc� e5�cc�cQ.M <br /> ����n�s5 :5y�c� ¢� c>�-k�n:S \eca2r�c•�y�_ `�S"l�t s5 ��.�5• <br /> to "b\ 1-34652- of C-�le (C. <br /> Inspection Form Included: Q <br /> Comments Included: Q Business Rceps <br /> Sig1na-�tu�e Phone Number <br /> Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:4D Incorrect: E X A M P L E 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />