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Waste Tire S & Inspection Report spection Report Number <br /> CalRecycle y p - 1177849 <br /> State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Fora Mage 1 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- { � � V � Inspection Type(Fill one) <br /> �Site Suffix: ` ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �— / If Referral,choose referral type(Fill one) <br /> Identifier: S U() J Q �(� C01A Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> U o� m Gt"�Cfi 1'1 U-(-gal l i n� <br /> Physical Address r L < co <br /> '-1 b� 1- tU111 1 Cf Vv L1 Jti11�� <br /> �� Inspection Date <br /> �15�-15 1 <br /> Time In Time Out <br /> Business Rep TitleO AM O AM <br /> 5 ® PM ® PM J' Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) -1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> d Active Q Passenger 4) Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) u r� <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 Q Hauler Q Agriculture Q Shredder ® 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 <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 EJ(n N <br /> a <br /> Q ® 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 ®In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> Commentsy 111 ; f S N <br /> J <br /> Inspection Form Included: Q z0q i 67 �q�1 �� <br /> Comments Included: ® 7 // <br /> mes ep's ignature Phone Number Insp t is Signature hone Number <br /> INSTRUCTIO ON BAKK [Correct: Incorrect: X EJXJA e 1112131 <br /> 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop <br />