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Oa Waste Tire S & Inspection Report' ipection Report Number <br /> CalRecycle p p - 1177849 <br /> State of CaliforniaCal'dornia <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 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- { � ^ 1 /� � _ Inspection Type(Fill one) <br /> �Site Suffix: l j v 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocaltTOLk <br /> If Referral,choose referral type(Fill one) <br /> Identifier: S a() r� G (� CO1A 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name "' Inspected By Inspector <br /> �tome>- Ml��cr;� <br /> Physical Address r L <br /> q�� A 1�tOnl 1 W Ll� - <br /> �D <br /> CA � 1S Inspection Date <br /> Time In Time Out <br /> Business Rep Titl n 1 0 AM 0 AM <br /> {��1 -� I 5 ® PM ® PM <br /> V7^��1� ����s 1 ar�5 �1�/'• JJ- <br /> JJ f 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 0 Passenger 40 Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler I* Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) 14 <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 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 <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EJC7) <br /> 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 ®In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments1JlfC`tr�1 til ka 4 'i lZ 1 r1S�Q,l {rr �IN f S VO J �� <br /> u <br /> 13J'nl -. <br /> Inspection Form Included: <br /> Comments Included: <br /> �- I 4wdin—esoeps(dignature Phone Number Insp t is Signature Phone Number <br /> INSTRUCTIO ON BA K [Correct: Incorrect: EXAM 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop <br />