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Waste Tire tAo gey °, DT�spectio�i -p(or� Inspection Report Number <br /> State of California <br /> CalRecycle <br /> CalRecycle 181(Rev. <br /> Dept.of Resources Recycling and Recovery Cal Recycle) s ey Form <br /> o?m o Page { <br /> I 1 - 1242377 <br /> Part A- Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� � � � o C) � Inspection Type(Fill one) <br /> Site Suffix: !) 0 Routine 0 Re-inspection ' 0 Referral 0 Observation <br /> Local \ If Referral,choose referral type(Fill one) <br /> Identifier: �0.1n �6CeLt u\ Cp Vv� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> J� \A�• X52_W��� Q-�.J e, _ <br /> /+ Inspection Date c) <br /> ` �31 Time In Time Out 1 <br /> Business Rep Title , 0 AM I C) Q AM <br /> �A QPM 0 PM <br /> S4 \0.V s V1n.� w h�C Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 14 7 9 Active 10 Passenger 0 Generator 4D Outdoor93 <br /> O 0 Closed 0 Altered <br /> ��� Latitude 0 Hauler _ 0 Indoor S y <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <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 /> Notice Of Violation 0 Extension <br /> 0 0 . PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 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 /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 <br /> Is In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments <br /> Inspection Form Included: 0 A4, <br /> hyA <br /> ?fit-Y6�-3zg <br /> Comments Included: 0 <br /> Bu a Rep's Signature Phone Number nspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />