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Waste Tire Sui Bey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 11 - 1226240 <br /> CalRecycle 181(Rev. (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- I O _ O r Inspection Type(Fill one) <br /> Site Suffix: I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: SC�� To a.Q L'n CU u 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name _ I Inspected By Inspector <br /> Physical Address �S CpO <br /> ----- <br /> S�OC'/�'L'f p11 C 5215 Inspection Date <br /> A <br /> 'f Time In Time Out <br /> Business Rep Title I AM O AM <br /> l 10 PM ! 0 V ® PM <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 /> 0 Active 0 Passenger ® Generator 0 Outdoor <br /> Latitude O 0 Closed 0 Altered 0 Hauler 0 Indoor <br /> GPS <br /> O 0 Inactive ® Truck <br /> Longitude - 0 Planned ® OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) _ <br /> 0 New Tire Dealer 0 Auto Repair ® 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 ® 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 /> 0 0 § - 0 Notice Of Violation 0 Extension <br /> PRC 42951 Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> a <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations a <br /> 0 0 Other:§ <br /> r <br /> Comments 1 ) 5 Pt , per4way-AN <br /> l 1 <br /> N�j U iO�u Clv�1��_-CcttS CullCern <br /> Inspection Form Included: <br /> Z09- 131-1I <br /> Comments Included: <br /> B i ess Rep's ature Phone Number Inspeck6rls Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAM 11213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop <br />