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Waste Tireey & Inspection Repon Inspection Report Number . <br /> CalRecycle Cte of aaRecycle1ifornia 181(Rev.10/10) I1 - 1242302 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A-S_urvey__ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 I�D <br /> _ Qj r S Inspection Type(Fill one) <br /> Site Suffix: D v 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S blY) J(D 0.y n C A3.AntA0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Y Inspected By Inspector <br /> Physical Address ) ESCOTTO <br /> CA l 52i4D Inspection Date � / D l � I <br /> Time In Time Out <br /> Business Rep Title AM AM <br /> O O O PM 1 b a 5 � PM <br /> �. a r. �ti)Ct�n c.r W U r�(L�' <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 /> db Active 0 Passenger ® Generator 0 Outdoor? <br /> O 0 Closed 0 Altered N 1A <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned ® OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 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 l /�� <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other S�4 Wqg Fabl l c ct,6n <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 /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 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 EX7) n <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/CalAecycle Enforcement <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 e In Compliance-No Violations o <br /> 0 1 0 1 Other:§ <br /> Comments ,• ,moi r� la c.�ti 1C' IJ-SGC I1t��0{?n �j� r ��� u`� t- ld'ntt i�lc- <br /> IJJ fS (T� (,tncern• <br /> Inspection Form Included: 0 444 ( )-74_7_ <br /> f <br /> Comments Included: 0 �� �� �v9 3)7 9 <br /> Bus' ss Rep's Signature P one Number Inspe 's Signature PFione Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: ( E X A M P E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop .LE ® 0 <br />