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Waste Tire SL. ✓ey & Inspection Report. Inspection Report Number <br /> CalRecycle State of California 11 - 1210325 <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- , r _ O Inspection Type(Fill one) <br /> Site Suffix: 7 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �- If Referral,choose referral type(Fill one) <br /> Identifier: Sar oag�`^ \ ,.�V �.r Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name w Inspected By Inspector <br /> Physical Address - <br /> 2 7�"1 5 41C.5e- C_CL� <br /> C'-\t ko V-\ 0-s\ 2 <br /> CCl 15 Inspection Date / , 1 3 <br /> Time In vvv Time Out <br /> Business Rep Title ! �/� O AM O AM <br /> 7 "�woc �rG"r LQ_ 2 l V7 Y� J " _ . � 0 PM O O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ' 6 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> fIl Active Q Passenger • Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> 0 Q Inactive A Truck <br /> Longitude - Q Planned Q 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 Q Hauler Q Agriculture Q Shredder &Other Crx-c'Ck A4*_i\,a�OLC'Fl)1`� <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 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 /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years N <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 /> Other: <br /> 0_L0_Q § <br /> Comments � ` <br /> �'+X Pec �� rz 42N)n VNIAs <br /> �,.� � �tJQS \ <br /> Rcexiz,��S S �L S 6�eY� C ce c��2 ' <br /> Mn���o� :�v`S -of- ARC—&-s O�- C.0 P-y v\ <br /> Inspection Form Included: Q <br /> Comments Included: T - ���-3�� <br /> Business Rep's Signature Phone Number Inspe tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X � E X A M P L E 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® . <br />