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Waste Tire Su, rey & Inspection .Report inspection Report Number ■ <br /> CalRec cle State of California <br /> Y CalRecycle 181(Rev.10/10) 11 FormPage 1 1 1177966 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- n t-7 _ /\ ( Inspection Type(Fill one) <br /> Site Suffix: / �J 0. Routine 0 Re-inspection 0 Referral Q Observation <br /> Local 1 ]. If Referral,choose referral type(Fill one) <br /> Identifier: S A tl J QC(,�j i C�t(�l l 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name LL Inspected <br /> Ins ected By Inspector <br /> 9_055 04 b A3 _TI­4_L d 4( J tt,f _ ) <br /> Physical Address <br /> Inspection Date 7 / l a <br /> —V �� Time In Time Out <br /> Business Rep TitleI S O AM 7 0 AM <br /> ® PM J ® PM <br /> - —- — - - - 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 Pass�nffger 0 Generator 0 Outd�000r <br /> Latitude D 0 Closed 0 AlterelA 0 ��A 0 Indoor)/� <br /> O 0 Inactive O Truck <br /> Longitude - 0 Planned 0 OTR O End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer ® 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 � Extension <br /> O O <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 /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 E)C7) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 _ m <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators (9 In Compliance-No Violations o <br /> 0 0 Other:§ rr <br /> Comments 4)1�. � 1a,� U N.1 Td <br /> a J a A�i UVII o f c vk- c0 <br /> N oke glnsaNo A?U OA S')!- <br /> Inspection Form Included: 0 P1414 ii, <br /> Comments Included: 0 ��_� ��" <br /> Business Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:e Incorrect: � W E X A E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C FA <br />