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Waste Tirette & Inspection Re „Ir, Inspection Report Number <br /> CalRecycle y p p _ <br /> State of California <br /> Y CalRecycle 181(Rev.y(cal Survey Form - Page 1 1 - 1176484 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A - Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 � � � '01 <br /> Inspection Type(Fill one) <br /> Site Suffix: I' Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 6t n OU u1� � Q CHP Q CalRecycle 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name WWW Inspected By Inspector <br /> Physical Address <br /> �J�1�� S. �r�nLh �m(� b�-v�• <br /> t 1 �� Inspection Date <br /> Time In Time Out <br /> JJI ` <br /> Business Rep Title O AM O 0 O AM <br /> 0 PM 0 PM <br /> b UL�v- <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 /> Active ® Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use ® Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> A Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder (6 Other qojf;11101 . sev u- <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 m / 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 EX1) N <br /> a <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 ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments nt T �1 n5 1 pq�o f t <br /> *ft, A-1d), 0-wN u rq's C <br /> fel, <br /> Inspection Form Included: Q 6 <br /> �j 7 In <br /> Comments Included: ®I - - _ - - <br /> s Rep's Signature Phone Number _ Inspe is Signatu hone Number <br /> 62081 <br /> INSTRUCTIONS ON CK [Gorrect.,0 Incorrect: E X A P L 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C V <br /> © 0 <br />