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Waste Tire SL' ley & Inspection Report Inspection Report. Number ■ <br />State of California <br />CalRecycle 11 - 1177550 <br />CalRecycle le 181 (Rev. y(Cal Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Survey <br />A - Qiir in.. BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPID -Inspection O <br />Site Suffix: 6 "� <br />Inspection Type (Fill one) <br />0 <br />9 Routine 0 Re -inspection 0 Referral 0 Observation <br />If Referral, choose referral type (Fill one) <br />0 Educational Visit 0 Other <br />Local r _ 1 <br />Identifier: Soh J <br />G0.q V t r W V Y�`` <br />0 CHP 0 CalRecycle 0 Complaint <br />Business or Facility Name <br />l5kucv�c_o.v <br />Inspected By Inspector <br />v ense.5-5 <br />Physical Address <br />a1 _ l 1 �' %A, <br />0 <br />es <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />` _ -152Z6 <br />Inspection Date 'L �'1 1 <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Time In Time Out <br />Business Rep Title <br />0 AM Q AM <br />1 � ' � � � Z ' C� � <br />I nv ► �- G& ca �, � -f�< r. <br />QPM ®PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) 1 <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />® Active <br />0 Closed <br />0 Passenger <br />0 Altered <br />1p Generator <br />0 Hauler <br />0 Outdoor <br />0 Indoor <br />O <br />GPS Latitude <br />0 Inactive <br />• Truck <br />O <br />Longitude - <br />0 Planned <br />0 OTR <br />0 End -Use <br />0 Container <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair is Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br />0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V T A7 HAULING AND MANIFEST REQUIREMENTS <br />0 <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Other: § <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EX7) <br />0 Referred / CalRecycle Enforcement <br />0 In Compliance - No Violations <br />Comments \ ' <br />.- <br />C11 - <br />N n k., <br />rn <br />Inspection Form Included: 0 (V,5)7 _4 <br />Comments Included: 0 <br />Business Rep's Signature Phone Number Inspect is Signature Phone Number <br />�,( 62081 <br />INSTRUCTIONS ON BACK Correct: Incorrect: � W NJ IIIIIIIIE X A M P L E 1 2 3 <br />■ e CopafRecyci� Yellow Copy: Operator Pink Copy: LEA © ■ <br />N <br />CV <br />N <br />0 <br />i <br />w <br />0 <br />z <br />