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Waste Tire SL.. ✓ey & Inspection Repoi , Inspection Report Nurnber <br /> CalRecycle State of California T 9 <br /> CalRecycle 181(Rev.10/10) �1 1�"'�/ey ��A`" ',� page 1 L - 1. �_. l 6 3 5 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) u v <br /> BLUE OR BLACK INK PEN <br /> Part A- Surve <br /> Business Profile Inspection Details <br /> TPID- � � � � � � � QInspection Type(Fill one) <br /> Site Suffix: I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �- If Referral,choose referral type(Fill one) <br /> Identifier: - �� J o �j h C0LlX1 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address ) �C( l..-S06 <br /> 1 Inspection Date 7 / J � / <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> I • I SS 0 PM ® PM{rte 0 T3 uI' <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 /> ' IS Active 0 Passenger 0 Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> 0 0 Inactive @L Truck <br /> Longitude - 0 Planned 0 OTR 0 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 M / m / m <br /> 0 .40 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 A <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 /> f <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 <br /> in Compliance-No Violations o <br /> 0 0 Other:§ <br /> i <br /> Comments p XA 1(\0., V'o(A' Al J� 1 11�nP Al D^ Des1 O T(x e 11v Qr\-,(�N Z [A atc <br /> U + lti <br /> Inspection FormIncluded: 0 <br /> ZIP <br /> Comments Included: <br /> usiness Repi ti6nalur Phone umber Inspe is Signature P one Number <br /> INSTRUCTIONS ON BACK C Incorrect: E X A M P L E 1 2 3 62081 <br /> ® ite Copy: cl Yellow Copy:Operator Pink Copy:LEA ® ■ <br />