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Waste Tin, jL. Jey & InspecUon Rep' Inspection Report Number <br /> CalRecycle State of California <br /> CalRecycle 181(Rev.10/10) M/�®� ®�Q(hnl Page <br /> �1 g e 1 11 1245383 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) � �/ \' i 9 1 C`]b� <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/ &Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: L) n Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> PhaAddress <br /> Inspection Date <br /> Time In Time <br /> a Out <br /> 0 AM <br /> Business Rep _� Ti�tlee�c� ( / v J O PM ` � S� & 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 Q Passenger • Generator 0 Outdoor <br /> O Q Closed Q Altered ' 7. — <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 46 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q 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 /> V1 A I 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 m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE 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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •ryn Compliance- No Violations o <br /> Q Q Other:§ <br /> Comments ` <br /> t <br /> i <br /> yr Ll�-�1 C <br /> Inspection Form Included: Q <br /> Comments Included: �� <br /> �iness Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />