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Waste Tire SL. Jey & Inspection Repon inspection Report Number <br /> CalRecycle State of California 1 <br /> CalRecycle 181(Rev.10/10) �1 011e/� �11r� ���f� Z 1 1177790 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) SSI!A �Y o <br /> e I <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / t Inspection Type(Fill one) <br /> Site Suffix: 9 -7 L � �1 u b ` Q Routine ® Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��h. Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility-Name Inspected By Inspector <br /> L\"� `'�Gl,eirZ''.�.�a .i f� ems'y'C�`►'�i'�.� <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title ®AM SAM <br /> r t G' ' D 0 O PM � ` O PM <br /> '%0_Vl �� ���'" 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 /> ® Active ® Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> G+PS Latitude & Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q End-Use ® Container <br /> Q Planned Q OTR <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 ® 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 Q - �Notice Of Violation � Extension <br /> 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 Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 EX7) 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 O In Compliance No Violations o <br /> Q Q Other:§ <br /> Comments <br /> G efco PteAh PA 4CL.01N <br /> Inspection Form Included: Q <br /> Comments Included: ® � 6a <br /> Business Rep's Signature h n Numbe*PinkC <br /> tur Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator ® ■ <br />