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i <br /> ti <br /> Waste Tireftey & Inspection Repo Inspection Report Number <br /> State of <br /> CalRecycle calRecy le California <br /> 181(Rev.10 10) I 1 -11- 768J. 4 <br /> • <br /> Dept.of Resources Recycling and RecoveryCalRecycle) Su rvey Form - Page 1 <br /> Part A-Survey l BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 0 Inspection Type(Fill one) <br /> Site Suffix: t J ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S(,t,l� J d(( (� Cp � Q CHP Q CalRecycle Q Complaint O Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 11 ` a <br /> LCAddress <br /> Q,\0 d A t-GC D �G1.Physg e n <br /> 0 C <br /> Inspection Date � / 0 <br /> 0 a / <br /> i pL <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> I f 1 5 ® PM a - v 0 ® PM <br /> ' Ou�ne.t <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 3p (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' 1 41 Active ® Passenger 0 Generator ® Outdoor <br /> GPeJ Latitude <br /> O Q Closed O Altered <br /> , <br /> Hauler 0 Indoor <br /> O Q Inactive O Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer ® 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 /> O O <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 /> 0 Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 Q 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 /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 0 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 1 Q1 Other:§ <br /> Comments l �1,j�t o iZD� �( C I <br /> NCJ U i a 11AA104) a r a f 1,6,9 off' C0.0cQ1'n , <br /> Inspection Form Included: Q �h CA � <br /> Comments Included: ' \ , _ X _ <br /> Business Rep's Signature Phone Number tnsp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: E X A P L E 1 : 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink opy:L ® 0 <br />