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Waste Tire SL Bey & Inspection Repor. <br /> Inspection Report Number <br /> CalRecycle State of California I 1 0 1196712 <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- ' S 1 _ O 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: �0 rV� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name w Inspected By Inspector <br /> �edW0.0 -1 - ` b l �l "►' \T 1 Q <br /> PhysicalA dress <br /> S\Coe\off Inspection Date 1 1 / -Z <br /> Time In Time Out <br /> Business Rep Title I © 1 10 AM 1 © *AM <br /> QPM ® QPM <br /> �eS�S ���ehe2 Quark M �. <br /> -- Operational Status The Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' T 0 Active Q Passenger 0 Generator Q Outdoor <br /> o Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive Q Truck <br /> Longitude _ Q Planned 40 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) of <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 S��ec 'Z :xr``� plc'v <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 Q Q Notice Of Violation Q Extension <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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q 0• 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <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 o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q 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 •In Compliance-No Violations o <br /> Q Q Other:§ <br /> - z <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: 4 M Al ""-� - ��� y �2 <br /> Business Rep's S' ature Phone Number nspec is tignature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: N_/ (�) 9f EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />