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Waste Tire SL. ,iey & Inspection Repon .Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1242372 <br /> CalRecycle 181(Rev.y(Ca[ 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- /� CN I � Inspection Type(Fill one) <br /> Site Suffix: "� (7 `Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> a-r �Of)l. V V n Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> PaY.e�,l 0. t � "� L"I. C_ <br /> Physical Address <br /> SOCIO V7Ve \•oy\V <br /> 1 SZ,I Inspection Date O 2— <br /> C 2 / <br /> ,IL,–/, Time In Time Out 1 <br /> Business Rep Title ' 0 AM 0 AM <br /> `PM � � � 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> t, <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> "I 0 Active 41 Passenger 0 Generator Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive 0 Truck <br /> Longitude – Q Planned OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 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 <br /> Q Q 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 EXi) <br /> a <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 /> Commentsak <br /> Inspection Form Included: D -SOo� 209^ h <br /> Comments Included:. [� <br /> B Hess epV signatur k, Phone Number Alnpectis Signature Phone Number <br /> INSTRUCTIONS ON BACK rrect:0 Incorrect: IEIXIAIMIPILIEI 111213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />