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Oa Waste Tire Skey & Inspection HBporle Inspection Report Number <br /> CalRecycle State of California - <br /> CalRecycle 181(Rev.10/10) �u iii/®� ®r� m �9�® 11 1245058 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Y e Page <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 ? 4 ^' - Q ' Inspection Type(Fill one) <br /> Site Suffix: 7 ( ) e Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� Ugh �tf\,cyti, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> PhysicalAdSdCeG viz1:,111¢ <br /> 134-5 ,_J- LO(3L6 <br /> Inspection Date <br /> ,� Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> ` � PM 3 ` 8 � PM <br /> �U)l YVUA-d 10tjU►'�. C,cv llQ.� -- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 'n 7 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 U_ Active 0 Passenger 0 Generator 0 Outdoor <br /> o Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive 0 Truck <br /> Longitude - Q Planned a OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader 0 Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> . Service Station Q 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 <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 /> 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 N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E)CT) 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 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance-No Violations <br /> Q 1 Q 1 Other:§ <br /> Comments - <br /> 4tu vlac G <br /> Inspection Form Included: Q <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number lnspecwrzzwature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 incorrect: rJ EXAMPLE 1 2 3 62081 <br /> 7X* <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />