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Waste Thr Sugay & hspecUon Report-Anspection Report Number ■ <br /> CalRecycle CalRecycle lete of l'fornia 181(Rev.10/10) p �r��/�(o��/� f�r (� n 1 m 242382 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) S u" ` "��J Form"" — Page I _ <br /> Part A-Survey BLur= OR BLACKIIgK PEN <br /> Business Profile Inspection Details " <br /> -A L 'a <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: Z 76 c) 2- Z o ' Q Routine 0 Re-inspection Q Referral Q Observation <br /> Locala If Referral,choose referral type(Fill one) <br /> Identifier: ��� J� N Q� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> cx_wBusiness or Facility Name Inspected By Inspector <br /> Physical Address J / " <br /> Inspection Date /S 2 / 7 / <br /> Time In V Time Out <br /> Business Rep Title 9 AM S 10 AM <br /> �A 1 0 P v 7 0 P <br /> SbL.V o I "L C�'� �� � <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ii (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> L- . Active 0 Passenger e Generator Q Outdoor <br /> O Q Closed Q Altered <br /> ��� Latitude � Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR End-Use Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q 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 0 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 /> 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <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 /> Q 10 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 /> 2 <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 •In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> C®v�CPC K� <br /> Inspection Form Included: Q v/ ,�A Z ��/yj, - z l —f,22 <br /> AL <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspe or's Signature. Phone Number <br /> INSTRUCTIONS ON (BACK Correct:* Incorrect: � � q E X A M P L E 1112 3 62081 . p <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> i <br />