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inspection Report Number <br /> Waste Tire Su, Bey & Inspection Report <br /> CalRecycle state of California 11 - 1178011 <br /> lR <br /> CalRecycle 181(Rev.10/10) ��ey Form - Page � <br /> Dept.of Resources Recycling and Recovery(Caecycle) <br /> Part A-Survey <br /> _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: ` -7 d O 3 Cl 0 ( ® Routine Q Re-inspection Q Referral Q Observation <br /> Local c_ If Referral,choose referral type(Fill one) <br /> Identifier: �C•�rl SC:CvrV� 'l/ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ams 4V�D 4r--pcov- <br /> Physical Address <br /> LTi✓Vt'L UYL4- -- <br /> Inspection Date 5 � l <br /> Time In Time Out <br /> Business RepTitle AM @DAM <br /> 0 <br /> I C) ' l 0P OPM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> ® Active &Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that ap)ly) <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 ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m m N <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXT <br /> Q Q N <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> w <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities — <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ z <br /> 6 <br /> Comments <br /> Inspection Form Included: r C_ p / <br /> Comments Included: <br /> ep's Signature Phone Number In p r' gnature Phone Number <br /> -- 62081 <br /> INSTRUCTIONS ON BACK Correct:l, Incorrect: ® g EXAM I E 1 1213] <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop L ® ■ <br />