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Waste Tire Ovey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 - 1210447 <br /> CalRecycle 181(Rev. (Ca] Survey Fora - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLU_ E OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� � � � � � © � Inspection Type(Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalI If Referral,choose referral type(Fill one) <br /> Identifier: ({ Utr 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> c <br /> Business or(Facility Name Inspected By 1 Inspector <br /> \1w�1Q'1� CSe51 <br /> Physical Addres o4 J SC <br /> Inspection Date / a r / I 3 <br /> Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> 0 P a ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) r7 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> AActive 0 Passenger IS Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> 0 0 Inactive 4D Truck <br /> Longitude — 0 Planned ® OTR 0 End-Use • Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 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 Tl�Sales <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 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 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 EX7) n <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 o <br /> 0 01 Other:§ <br /> z <br /> Comments <br /> 944?M l� G„S�rJ �1 t,, l!) <br /> 0 '- <br /> Inspection Form Included: //Z <br /> CtComments Included: D L912' 4 <br /> Ains Signature Phone Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS O BA �Correct:0Incorrect: X7 EXAMPLE 1 2 3 62081 <br /> K <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA © ■ <br />