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Waste Tire ®.auivey & 0ifl spec1 cn Ra r, Inspection Report Number <br /> CalRecycle State of California I l e 1245379 <br /> CalRecycle 181(Rev.y(Cal C� 11f w/oy Form <br /> If1f�1 - Page <br /> I <br /> Dept.of Resources Recycling and Recovery(CalRecycle) @��J Ili � IJ !1 Il t! CSH �i <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � ' � i� - ��l ry Inspection Type(Fill one) <br /> Site Suffix: 0 l/ I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: C Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Gi l 1 E)C enc , 2 c- <br /> Physical Address <br /> 10 -2-2- T� <br /> Inspection Date <br /> C./9- 'Is3D ce <br /> Time In Time Out <br /> Business Rep Title0 AM AM <br /> 3 : 2 � 0 PM � ' � a PM <br /> ncp <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Countho a/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger 0 Generator a Outdoor <br /> O Q Closed Q Altered <br /> G�� Latitude Q Hauler Q Indoor <br /> O Q Inactive #Truck <br /> Longitude - Q Planned Q OTR ® End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> i Used7ire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> • 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 /> V A 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 <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 /> 7 <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 Ap In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> Comments <br /> d✓ <br /> Inspection Form Included: Q ' <br /> ' <br /> Comments Included: ® <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: 7X:*:�]jEjXjAjMjPjLjEj 11 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />