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Waste Tire Stey & Inspection Report Inspection Report Number <br /> CalRecycle State of <br /> CalRecyclel1ia 181n(Rev.10/10) }� ® �1{ 11 - 1255835 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Fort 1 1 — Pager u <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- - Inspection Type(Fill one) <br /> Site Suffix: 3 d Z Li 07 - , 0 Routine 0 Re-inspection 41 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ® V;,� co 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address J�1 AT T v <br /> 1-37-5 W. c1\ac\e--c �� -- <br /> Inspection Date Z / C) <br /> V-� Time In Time Out 6 1 <br /> Business Rep Title —7 0 AM O AM <br /> C 1 L 0 PM 0 PM <br /> W'6se °�` "� "�C 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 /> 0 Active 0 Passenger IS Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 40 Dismantler 0 Tire Derived Fuel <br /> Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 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 I HAULING AND MANIFEST REQUIREMENTS <br /> O 0 0 Notice Of Violation 0 Extension <br /> 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 / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> a <br /> 0 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 /> 2 <br /> W <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities __ <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 /> 1� <br /> Comments T_ _ _ .l'. ;� 0 �t v�S2. r\w.P �2�0 C�i T►�� ��M�U'` <br /> L2o 16 <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:I* 7X7Cq:1jEjXjAjMjPIncorrect: LE 1 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop ® ■ <br />