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02 Waste Tiree & Inspection ReP90- Inspection Report Number <br /> CalRecycle State of California Y - 1176391 ■ <br /> CalRecycle181(Rev.10/10) Survey Form - Page 1 I1 117 6 3 91 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Dart A - Survey_._--- _— -_-_-___- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 r � � �r� Inspection Type(Fill one) <br /> �Site Suffix: l `� 0 oL I '9 Routine Q Re-inspection Q Referral Q Observation <br /> Local �- I If Referral,choose referral type(Fill one) <br /> Identifier: 5�i(,n JQ vl n CoU, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Fa ility Name I <br /> L Inspected By Inspector <br /> CUTO J G� O1 1 <br /> Physical Address <br /> 3 � I <br /> I),Is � � etL�f�i a io L Y) Inspection Date � <br /> L_0A�. C�I Time In Time Out / <br /> Business RepC�),Cj <br /> Title � � O AM 19 AM <br /> �b� Q ��r PM O PM- ---- - <br /> Operational Status Tire Type Business Role Storage Type <br /> ` <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I ® Active Q Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer ® 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 ® Other Ai4 r (8 C Ls- 4 p u f r <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 ® 14 CCR§18459.1 -Tire Program ID Number from CalRecycle M <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> v <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:§ ` 1^ 1 <br /> Commentsi! 7 i1X)� U0L 4,A I1_� 11 nsQP 10 D A(bru of\ -4f 1, 5 Ul Gke� a'rA <br /> u GAS f y <br /> Inspection Form Included: Q I <br /> Comments Included: — — --- - — -- o-- - <br /> BN.sine Rep's ignaWre Phone Number Insp_rSignature <br /> Signature one Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E I X I A JMP I L(E I 11 2 1 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA . <br />