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Waste Tire SL. .iey & Inspection Repor. Inspection Report Number <br /> State of <br /> Cdecycle CalRecyclelifornia 181(Rev.10/10) Surve Form - Page 1 I 1 - 1196490 <br /> Dept of Resources Recycling and Recovery(CalRecycle) Survey g <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 �7 L 1 Inspection Type(Fill one) <br /> Site Suffix: / y © V 2 3. l 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: GCX.V,., T0,,n V r" Cv, A 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ""'� '` ,7 Inspected By Inspector <br /> Ti [vs�, , q <br /> Physical Address M <br /> Ck <br /> Inspection Date I / / 1 <br /> 9s2oS Time In Time Out <br /> Business RepI <br /> ". c,,\ Title r ^\ AM AM <br /> C /�1r�Q. O � v Q PM � � V Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fillone only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> O ,, <br /> 0 Active 0 Passenger 0 Generator 0 O�utdoor <br /> PS <br /> Latitude 0 Closed 0 Altered ll////AAT <br /> (a' 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) Gr <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 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 /> 0 0 �Notice Of Violation � Extension <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 /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 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 EXTJ N <br /> _ a <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators o In Compliance-No Violations o <br /> O Q Other:§ <br /> Comments <br /> � w <br /> Inspection Form Included: 0L <br /> �:. ZoR-YBZ� asg5' . - /11fw�- 2�`�`�i$328 <br /> Comments Included: <br /> ' ess Rep's Signature Phone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: � � � FENAIMIPILIE1 111213 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />