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Waste Tire SL- ',fey & Inspection Report inspection Report Number ■ <br /> State of California <br /> CalRecycle 11 - 1242340 <br /> CalRecycle 131(Rev.y(Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Survey <br /> -S_urvee BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` I _ Inspection Type(Fill one) <br /> Site Suffix: ! * Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S Le)lou 1A Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> u:�. s--,,-L ` <br /> Physical Address <br /> �+ Inspection Date <br /> S'o 6thy-, (A �S-ZV5 l O 11 <br /> Time In Time Out <br /> Business Rep Title O AM ,) O AM <br /> 'M 1 .l Utli 11cr �' � V 0 PM � _l � ® PM <br /> S& a'b <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) O (Fill one only) (Fill all that apply), (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger i Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude ` mwt. Q Indoor <br /> O Q Inactive Q Truck <br /> I <br /> Longitude — Q Planned Q OTR O Eno-use Q Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Disr-ar'.+er O Tire Derived Fuel <br /> ® 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 /> O Notice Of ViCiabOn Q Extension <br /> Q O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadine <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / M / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E?C� <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> O O Other:§ <br /> Comments b, � S /✓ C. G{lzA IqL- <br /> Inspection Form Included: Q <br /> Comments Included: • �'tJ � <br /> Business Rep's Signature Phone Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: �(� EXAM' P 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink CA A ® ■ <br />