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02 Waste Tire Sunjoy & Inspection Report Inspection Report Number <br /> CalRec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Su �� Form - Page 1 1 1255790 <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- <br /> Site Suffix: I (,.� _ Inspection Type(Fill one) <br /> ( "� `Routine Q Re-inspection Q Referral Q Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: � ki�l CO-C, L);rl Ccr,.A-;,� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address I I 'VITL+ of'-D <br /> Inspection Date <br /> Time In Time Out <br /> Business Re Title 0 AM 0 AM <br /> I'Ck p" O PM ` � � O PM <br /> L SL 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 /> Q Active Q P sse <br /> Ca�S Latitude i Closed ger Q Generator Q Outdoor <br /> O Q Auer Q Ha leerdo�oar <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer ® Auto Repair Q 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 /> VA 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / 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 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations <br /> Q Q Other:§ z <br /> Comments �..�, ��cn-DJC <br /> C1+ ti t Cz rt el <br /> Y16tX IN'© 1��c�Lf Ci Zt,�+ tN Q�11t F��C��C.Grt.�e .-n.^ �C31ty <br /> rk YI G IGY a-Q� ' -tiu=4 I��c�ew a,z�2., 6b rV � �,�a to o s. IZ�rc�x�r c <br /> TTI 0# <br /> Inspection Form Included: QC- 44— <br /> Comments Included: Q r ' <br /> BLWIness Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [Co7rrec7t�*�IncOrr�ect' X��O�9��rEFXIAIM[PILIEI1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />