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03 Waste Tire Sway a hs� cVoo n Rept Inspection Report Number <br /> ■ ���Iili�UyYlri State of California rte, I� o - 1242283 <br /> ■ <br /> CalRecycle 181(Rev.10/10) <br /> y(Cal `gip fIC?Cl/7ey Form 6;Jage 1 11 12 4 2 2 8 3 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) �'JhJ.111 V l�}�" I1 Page� <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 0 ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: c� � (� q/�� 7fif'l 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Na/me L( Inspected By Inspector <br /> Physical Address 9 lot A Pi+rne 1 A <br /> Inspection Date <br /> Time In Time Out <br /> Busine1ss,Rep Title ( ® AM AM <br /> I t � � 0 PM � � 'S O 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 /> 40 Active 40 Passenger Generator 0 Outdoor <br /> O 0 Closed 0 Altered N!A <br /> GpS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive ® Truck <br /> Longitude — 0 Planned 0 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 ® Other0- C %-se <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 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> v <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 /> 2 <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments <br /> set, C �G <br /> Inspection Form Included: 0 <br /> Comments Included: �oct�!6 eP`� 7 <br /> Busin ep.'s Signature Phone Number I s 4cts ignature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A M P E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy L ® ■ <br />