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Waste Tireftey P& Inspection Rep Inspection Report Number <br /> CalRecycle calRecyclelifornia <br /> State of Ca181(Rev.10/10) _ 11 - 117 6 /'. 9 5 <br /> Dept of Resources Recycling and Recovery(CalRecycle) Su rvey Form Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � 1 , t ,� � � Q � - O j Inspection Type(Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local r� If Referral,choose referral type(Fill one) <br /> Identifier: S� /� I j f^� C01't( _ 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facilitye (✓ W Inspector <br /> �w UTInspected By A _ ` <br /> Physical Address 3 1 Es t& <br /> G <br /> Inspection Date / ` 0 <br /> S <br /> c � <br /> �J Time In Time Out <br /> Business Re tt Title O AM 0 AM <br /> PM 3 I 5 S PM <br /> �1(��1 <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 /> 3 3 ®Active Passenger ® Generator ® Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> O 0 Inactive Truck <br /> Longitude - 0 Planned OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 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 0 Extension <br /> 0 0 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 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 EXT) <br /> N <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 /> 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 O In Compliance-No Violations o <br /> 0 0 Other:§ IIL�11 _ 11 <br /> Comments u 1 pc�r-LIK4 —1 15 e�a►ti "(A �Yle <br /> i0 i0J) 1 - <br /> Inspection Form Includeqd- <br /> Comments Include — - C T 1� <br /> sinessRep's Sign re Phone Number Inspe is Signature P one Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correct:* Incorrect: E X A M 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop L ® ■ <br />