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Waste Tire Slug Bey & Inspection ReporfAnspection Report Number ■ <br />CalRecycle State of California I 1- 1242454 <br />CalRecycle 187 (Rev. (cal Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery(CalRecycle) <br />Part A - Survev BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPID - 5 7 L, e - <br />Site Suffix: <br />Inspection Type (Fill one) <br />W J <br />0 Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Local r- 1 <br />Sol J (0 t vl <br />Identifier: {1 0 Cjt,9 its n u^ <br />\J <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Business or Facility Name <br />Inspected By Inspector <br />r Iee.� w (A SVI <br />3 1lee <br />Physical Address <br />- <br />C� LU7�� <br />O 'CkOi c.CA- C 1� M 33'7 <br />Inspection Date A O I J 1 U <br />2j "I 1 1 <br />Time In Time Out <br />Business Rep Title <br />O AM O AM <br />J U 3 0 Q <br />e-wl P� (1� � � ons . mUr,�, cr <br />• ® PM <br />(9 PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) I <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />0 Active <br />Q Closed <br />0 Passenger <br />Q Altered <br />0 Generator <br />Q Hauler <br />Q Outdoor <br />0 Indoor <br />O <br />GPS Latitude <br />Q Inactive <br />Q Truck <br />O <br />Longitude - <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q 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 <br />Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other <br />Part <br />B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />Q Notice Of Violation Q Extension <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date m <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />(Required for NOV or EXT) <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q Referred / CalRecycle Enforcement <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />& In Compliance - No Violations <br />Q <br />Q <br />Other: § <br />J Ll <br />D l !ii �CJ "L Yl T 1'1� <br />Comments, <br />A11- L l^ <br />�l c14 S'1 c. �l� 1 l n�i (��t/�1LU� U-� �►' )ll <br />0 <br />IV f) V1I01 <br />II ]],,,_ IV -15 (of 6kfC_1X1S Un <br />Inspection Form Included: Q <br />Comments Included: <br />s 's Signature Phone Number Ins tor's Signature Phone Number <br />INSTRUCTIONS CON BACK Correct: Incorrect: E X A L 1 2 3 62081 <br />■ White Copy: CalRecycle Yellow Copy: Operator Pink Co : L <br />