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Waste Tire Vvey & Inspection Repos' Inspection Report Number <br /> CalRecycle State of California I 1 - 1186143 <br /> CalRecycle 181(Rev.10/10) Survey Form _ page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) VV <br /> Part A- SUCVe - BLUE OR BLACK INK PEN <br /> Inspection Details <br /> Ins <br /> Business Profile p <br /> TPID- I � � � _ �1 � Inspection Type(Fill one) <br /> �Site Suffix: C (/ 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Businessor Facility <br /> JName Inspected By Inspector <br /> La food 44o 4��Oa I <br /> Physical Address <br /> ��L� �( Su��C, o S 4 <br /> inspection Date <br /> LC,��� �5��q� l <br /> I �� 11 Time In Time Out <br /> Business Rep Title V /J (A AM �� `� ®AM/ <br /> O PM 0 PM <br /> - - <br /> —- -- - Operational Status Tire TypeBusiness Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> SO JS Active ® Passenger 41P Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ® 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility E FORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> -- -- FoNotice 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 EXT) N <br /> I � <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 l Q Referred/CalRecycle Enforcement <br /> w <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations o <br /> 010 Other:§ _ <br /> Comments .� i �� L Cr /U - /. �� .► <br /> Alp k] <br /> Inspection Form Included: Q �� <br /> Comments Included: Q �j -- <br /> Business Rep's Signa u Phone Number Inspecto s Signature - Phone Number <br /> �-� 62081 <br /> INSTRUCTIONS ON BACK [Correct,* Incorrect: X� q EXAMPLE 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />