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02 Waste Tireftey & Inspection Repo"Inspection Report Number <br /> State of <br /> CalRecycle CalRecyclelifornia 181(Rev.10/10) — ■ <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Survey Form - Page 1 I1 1210 4 7 7 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � 5 � � � � Inspection Type(Fill one) <br /> � © <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local t If Referral,choose referral type(Fill one) <br /> Identifier: SCAn-16) n�lU,I `( 'AA Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 4 Inspected By Inspector <br /> All �C11S l <br /> Physical Address 9 - L a eswrv <br /> 3"'70 W\A1 Lo x' vztk <br /> 5�0 clk'ocA q S LA5 Inspection Date 10 / 3 <br /> Time In Time Out <br /> Business Rep— fU W^ Title 0 AM 0 AM <br /> (d <br /> W 1� ei ptal,M31rn�r 1 l "1 0 PM 5 is 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 /> ® Active Q Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered ");q <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q 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 /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber 1 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder O Other t} Wdal"n 51vp 61eS <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 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 / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE 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 <br /> \ r <br /> l9 WJ�� WA S 1fly <br /> y!S o S Q,f"A& Q&_c,1j_pal <br /> Inspection Form Included: Q <br /> Comments Included: ® - ��-v-�'��'�� <br /> Business Rep's Signature Phone Number Ins for s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: E X A L 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink CV <br />