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Wase u ore Survey & MspecUon Rapt Cnspection Report Number <br /> G - <br /> State of California 1 1245190 <br /> CalRecycle �ppfr11p/ney Form o page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) l�J I V u u u �i <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 2 ` Inspection Type(Fill one) <br /> Site Suffix: I I t� 'i 'a Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: sce-C btf-) C�zwt� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> \L PXQS,5 CC) .J�"L'. <br /> Physical Address e - f 0 aouD�-fA—L w <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AMAM <br /> ��� 1.�' 7 G�•M.CS.L� �t�YI . �S! � � �J � PM �' ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count e/PTE) (FII one only) . (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active Q Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 9 Truck <br /> Longitude - Q Planned Q OTR Q End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 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 <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 <br /> 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 Ffl / 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 /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years a <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement g <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 Z <br /> 4 In Compliance-No Violations o <br /> Q Q Other:§ A <br /> Comments � � <br /> tY V <br /> C - 71c w� vQ••'. <br /> Inspection Form Included. Q 2 <br /> Comments Included: / �� � <br /> usiness Rep's Signature Phone Num nspec or's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:1* Incorrect: EXAMPLE 1 2 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />