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Waste Tireftey & Inspection Repv Inspection Report NUinber <br /> CalRecycle State of California _ 11 - - 176368 <br /> CalRecycle 181(Rev.10/10) Survey Form Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey <br /> _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � Inspection Type(Fill one) <br /> Site Suffix: ( —1 41 l 0 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ` / If Referral,choose referral type(Fill one) <br /> Identifier: �l,}LV, v�</1" l C�i��J1/�, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ECk__-_At.J e-�-4- i - 9 L <br /> Physical Address <br /> 0?11 b 63ca;�Cx lav �ic� , <br /> Q Inspection Date -7 / � � / ` <br /> ( /� l <br /> `��05- Time In Time Out <br /> Business Rep TitleSOAM <br /> nn AM � /�''� <br /> © � t2 O PM (/ . 0 V Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> ®Active o Passenger INP Generator ® Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q 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 /> ® 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 /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q 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 /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / Cl) <br /> N <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle LO <br /> Q Q 14 CCR§ (Required for NOV or EXn N <br /> 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Ln <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 /> 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 o <br /> Q Q Other:§ <br /> 6 <br /> Comments <br /> Inspection Form Included: Q <br /> -- jFPinkC.p <br /> Comments Included: ® Busine Rep's Ig t hone Number ature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: � V E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:operator © ■ <br />