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Waste Tire SL. .ay & Inspection Report ispection Report Number ■ <br /> Cal Recycle State of cle181California I 1 - 1178027 <br /> CalRecycle d R(Rev.y(Cal S u r ey Fo rm Page ] <br /> `� <br /> Dept.of Resources Recycling and Recovery(CalRecycle) �9 A ®! � 9 E E C4J�,1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 6 $ O l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SCG A J -b�'t� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Phy�al dress - r <br /> j <br /> n Inspection Date 7 / / / l <br /> �-i;r:L� rOvt fj$'a p j Ca <br /> Time In Time Out <br /> Business Rep Title ® AM ®AM <br /> 1 d J 0P C 5' �20PM <br /> zec <br /> Operational Status Tire 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 /> Q Active &Passenger ® Generator Q Outdoor <br /> O ® Closed Q Altered AIIA- <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR ® End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service 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 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <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 N <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 Q Referred/CalRecycle Enforcement <br /> 2 <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 1 Q Other:§ <br /> Comments <br /> &40 QluYL q.Wwmc, sh-'blT)L,\Pu) L,4Z .kcr <br /> Inspection Form Included: Q <br /> Comments Included: Q �y, ?62 S <br /> Busin ss Rep's Signature Phone Number cto s Anature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: EXAM ILJEJ 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C p : ® ■ <br />