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02 Waste Tire Su. rey & Inspection Report inspection Report Number ■ <br /> CalRec cle State of California <br /> Y CalRecycle 181(Rev.10/10) S 11 Fc�rn� - Page I1 1226570 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> PartA-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � - Q 1 Inspection Type(Fill one) <br /> Site Suffix: I / b 1 J 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �l If Referral,choose referral type(Fill one) <br /> Identifier: S.�,n J U rt, 01An� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 6 / '\ Inspected By Inspector <br /> Physical 'ress �5 J `-Uo-�a' r l7 VZ'i� - 1 j� 1 <br /> 3 9 v <br /> Int <br /> S5 �\) , \/o s rrn,�­, Ave , - _ --- ------ <br /> Inspection Date � 0 <br /> t\6+c,« Cfl 85337J <br /> Time In Time Out <br /> Business Rep Title 0 AM <br /> ,\ 0 <br /> (CJI Q PM I V Q PM <br /> -- -- - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) /x (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 PassprWer 0 Generator 0 Outdoor <br /> dA WA WA <br /> GPS Latitude Closed 0 Alt r 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> t <br /> Business Type(Fill all that apply) _ _ <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader n Dismantler Q Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> i <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Other ���yG Pk <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility rENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires i <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> m <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Dare m / m / <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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 /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ w <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 t f <br /> Sei12 cu n <br /> - N 1 ok eA�m � 6 V\ ce i(1 <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: EXAM L 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop <br />