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Waste Tire SL. Bey & Inspection Repor. Inspection Report Number <br /> CalRecycle State of cle 181(R 11 - 1178040 <br /> CalRecycle 181(Rev.y(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 Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: r 3 -7 7 S {j O 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: -Sr' �cc ic�v��- Lf3tM�ILf Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> g <br /> Inspection Date <br /> �.,�.►tiPo C-� W 5 adv �� ,lt l <br /> Time In Time Out <br /> Business Rep Titleii Q AM Q AM <br /> l <br /> C _ �p l d C7 O PM l l � 0 O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) j Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' / 9 Q 8 O 0 Active Q Passenger 0 Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude Q Hauler 19 Indoor <br /> O 0 Inactive O Truck <br /> Longitude - Q Planned 0 OTR Q End-Use 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 0 Hauler 0 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 Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <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 <br /> In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> z <br /> Comments <br /> cc V <br /> Inspection Form Included: <br /> Comments Included: ® e / <br /> sin R p's Si ature Phone Number p or' Si nature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:0 Incorrect: E X A L 12 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C py: ® ■ <br />