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Waste Tire ey & Inspection RepVI l— "Ispection Report Number <br /> Cal Rec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) SurveI1 12 2 6 6 4 0 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) y Form - Page 1 <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- l Inspection Type(Fill one) <br /> Site Suffix: ` _` J 'o Routine Q Re-inspection Q Referral Q Observation <br /> Local , ��u� If Referral,choose referral type(Fill one) <br /> Identifier. San J 0 Gt Lt n Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> R��el I, g c u L') n , LLL <br /> Physical Address I FS(.v�v <br /> --- <br /> S�a�,�-ion c A QS2�5 I Inspection Date -I <br /> Time In Time Out <br /> i Business Rep Title V : aC , AM ' <br /> 1 I 0 AM <br /> O PM <br /> nn J 3 Q PM <br /> N) <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) Q l) 3 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> u I 0 Active ® Passenger 0 Generator ®Outdoor <br /> GPS Latitude Q Closed Q Altered <br /> Q Hauler Indoor <br /> O Q Inactive ItTruck <br /> Longitude - Q Planned Q OTR Q End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 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 ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Q �Notice Of Violation Q Extension <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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date V / <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 /> v <br /> u <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 /> LU <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 Q In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments (e,.- 1 j15(L¢�UCI(9f1 ( ` ) 5 (� kC., a nok 42/ �OI�0l tai <br /> co M'C-(VAS <br /> Inspection Form Included: nnq_j�y.� <br /> Comments Included: V_ 7DO mot3111 <br /> t;_;usiness Rep's Signature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ?V FETXIAIMIPILIEI 111213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />