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Waste Tire SL. Bey & Inspection Reporo6 ,Inspection Report Number ■ <br /> State of California <br /> CalRecycle 11 - 1230097 <br /> CalRecycle 181(Rev. (Cal Survey Form - Page 1. <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> TPID- inspection^ tl...� � � � � /^ ' Inspection Type(Fill one) <br /> Site Suffix: `� l V ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ( / If Referral,choose referral type(Fill one) <br /> Identifier:. SC40 J C) 0AA- 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1 <br /> Inspected By Inspector <br /> ZUOL <br /> Physical Address �C �O'�� <br /> C-1 (AkLAJ CA <br /> Inspection Date <br /> 1 J Time In "I Time Out J <br /> Business Rep 1 `] -f r <br /> Title U ®AM ® AM <br /> �J01r1��\ r(dt' V�. 1' LA0 w C(' O PM 1 QPM <br /> \lk <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) t'] (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> `/ 0 Active 0 Passenger 41 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> 0 0 Inactive 9 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair f)Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation Q Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <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:§ 1^ 'I . ], ], ,�, .1 <br /> Comments c1iCV' �)(A�J�C.�1�c� 1 � �,��2� A r 11 S C�1 Q�l,�'O1 �� vW►1 <br /> NELI% Cl3 c oln us lT}C(}11C�rn_ <br /> Inspection Form Included: 0 Cy / / `y q <br /> Comments Included: �"/ o�,t <br /> sine Rep's s4nature Phone Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAM , L 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: E © ■ <br />