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Waste® Tirefte & Inspection Rep" Inspection Report Number <br /> State of California <br /> E <br /> CalRecycle <br /> CalRecycle 181(Rev. (Cal 11 - 12 2 6 2 4 7 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A-Survey _ _- BLUE OR BLACK INK_PEN <br /> Business Profile Inspection Details <br /> TPID- ( ^ A q ' l 1- M I In 2 tion Type(Fill one) <br /> Site Suffix: 1 d 1 1 lD _ Routine Re-inspection Q Referral Q Observation <br /> Local ^ If Referral choose referral type(Fill one) <br /> Identifier: f\ CO U1� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name `- Inspected By Inspector <br /> Physical Address f l�L Rd1 LLL - l C—5 coh <br /> Inspection Date I / Q <br /> S�a�.k�n CA �Sa►s <br /> Time In Time Out <br /> Business Rep Title AM l I ` ) ® AM <br /> O S O oPM 1 "\ s OPM <br /> pNv�s W 4c) S �t��e r- <br /> --- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1p `a, q <br /> ®Active ® Passenger ® Generator a Outdoor <br /> GPS Latitude 0Q Closed Q Altered <br /> Q Hauler 0 Indoor <br /> O Q Inactive i Truck <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 HAULING AND MANIFEST REQUIREMENTS <br /> Notice 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m M) s <br /> / ml -� <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 EXE 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 Q In Compliance- No Violations o <br /> Q Q Other:§ <br /> Comments PS` 'qCA 0 oe — 5 �.. �dne� U���►5 <br /> Sce, �S F s m <br /> Inspection Form Included: 1-' � <br /> Comments Included: ��_���- �3Q1,1 <br /> Business Rep's Signature Phone Number Ins p or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAMPLE 1 62081 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />