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Waste Tire au <br /> ve8c Inspection Re oi( l""Inspection Report Number <br /> CalRecycle statCaleof Californiae 181(Rev.10/10) y p m 1 - 1245185 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form gage 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ® � J -7 � � !�, � Inspection Type(Fill one) <br /> Site Suffix: l (�J (-� 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �(�� Ji)-� C' Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Ccs Ghe vlo b� ,- Ccrn,C;k <br /> Physical Address <br /> Inspection Date <br /> Time In tTime Out <br /> Ti <br /> Business Rep rifle j , l( �-- � PM � Z j rO AM <br /> . PM <br /> bA*C�_'mu_y h V u r}� <br /> Operational Status Tire Type Business Role Storage Type <br /> _� <br /> Tire Counle/PTE) e (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t,eWh� / `-r <br /> �-�/ 10 Active ` Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> G�� Latitude Q Hauler IS Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O 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 0 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 I 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 /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> n <br /> a <br /> N <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Referred/CalRecycle Enforcement <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 2 <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 <br /> Q Q Other:§ / z <br /> Comments <br /> L4y� hd ' <br /> w- <br /> Inspection Form Included: Q , -M 4715-400 <br /> Comments Included. <br /> Business Rep's Signatu a Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: I EIXIAIMIPILIEI 1112 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />