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..•:rr7� iiGlJis.lE.:S .. 4_:_s..-.�iaG..�...7-..r:.::-. -:;.:.:.-_..._.-:fira:.�.::usa a .:.-s-......-.a...-s.__._._ _�_. .___.___.. <br /> � <br /> Inspection Repo Inspection Report Number� Waste Tire "Urly & Insp _ <br /> CalRecycle State of California 11 - 1226290 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID Inspection Type(Fill one) <br /> f` <br /> Site Suffix: i Z 3 to i 6, V ( ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 47 LLe Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> l J;'U-)'In A-W�O 1300 CT I ;r 3 � - l 0 t /3o f, '�I F. /0 <br /> Physical Address ✓ <br /> Inspection Date <br /> �t x- , S- <br /> �•1-� Time In Time Out <br /> Business Rep TitleAM <br /> ®AM <br /> CJ <br /> : 3 o 0 PM /� o 0 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) 1 f 3 <br /> ® Active ® Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <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 /> 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 • Auto Body ® 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 _- _ _ ®Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> ® 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 Datero <br /> • Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§ - (Required for NOV or EXE N <br /> 18459.2.1 Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q Q Referred/CalRecycle Enforcement <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers � <br /> w <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance-No Violations <br /> Q Q Other:§ - <br /> Comments <br /> G"t���.v�����s�w/h_�c _ <br /> Inspection Form Included: Q <br /> Comments Included: ® Busine Re s Signature Phone Number n�tor's Signature Phone Number <br /> - 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � EXAMPLE 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ■ <br />