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Waste Tire SL. Bey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 11 - 1242336 <br /> CalRecycle 181(Rev.y(Ca[ Survey Form - Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- i C -2 6 Inspection Type(Fill one) <br /> Site Suffix: 1 1 O Routine Q Re-inspection Q Referral Q Observation <br /> Local ^ 1 If Referral,choose referral type(Fill one) <br /> Identifier: (fin (jet t,�1 1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> _ <br /> Physical Address 1 Cs LV � <br /> Inspection Date 7 / 1 8 I [J <br /> Time In Time Out <br /> Business Rep C- TitleM ® AM <br /> Sh C"�C� ,ll!1 1`1* la I � O PM � � V � 0 PM1 <br /> Operational Status Tire Type Business Role Storage Type <br /> i Tire Count(Whole/PTE) G (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> :] ® Active ® Passenger • Generator • Outdoor <br /> O <br /> Q Closed Q Altered <br /> G pSLatitude Q Hauler Q ln(faa <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Conta,ner <br /> B,i—ness Type(Fill all that apply) <br /> %Ww Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Dw,v-.(j c•_w' <br /> used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Sorvice 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 /> - Q Notice Of Violation Q Extrusion <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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> I <br /> IQ 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 o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 10 Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q li Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators B In Compliance-No Violations /o <br /> Q Q Other:§ l I <br /> Comments ,_ ,�.. u4 �-� 'h� lL� Yl�S d <br /> 01 A)) fin'j1 1. MS <br /> Ny1'01ZAVIvts 19S u,fe (01)(trfl- <br /> Inspection Form Included: Q I �,v� hG� 5196S y <br /> Comments Included:® � (A&Lh�t�q 31 s7g <br /> Business Rep's Signature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: I EXAM P-1 L 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co <br />