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Waste Tura SL.. Bey & Inspection Repar ,, Inspection Report Number <br /> CalRecycle State of California AA 11 m 1242456 <br /> Caycling ande 181 <br /> cover (Cal Sunfa (/ r�� ® page <br /> Dept.of Resources Recycling and Recovery(CalRecycle) 664664������ ��JJ <br /> Part A - Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ © Inspection Type(Fill one) <br /> Site Suffix: • Routine Q Re-inspection Q Referral Q Observation <br /> Local i t If Referral,choose referral type(Fill one) <br /> Identifier: J OG Li Loi 11 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _ I <br /> Inspected By Inspector <br /> s _ ) <br /> Physical Address 3 0 1 CS 60- <br /> W_ <br /> Inspection Date 16 <br /> Time In Time Out 1 <br /> Business Rep Title 0 AM ® AM <br /> Q PM I v 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 0 Active ® Passenger ® Generator le Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive ® Truck <br /> Longitude — Q Planned • OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair Q 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 Other lJt��u r1'bn/ Cb c,S�'J u G L� U"\ <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 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q 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 /> r <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 ® 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance-No Violations o <br /> Q Q Other:§ _ <br /> Comments pZN ��5 <br /> Inspection Farm Included: G <br /> Comments Included: a <br /> 4..� .46 (.'11 l 1 � uU 9-3117 <br /> $ <br /> Business Rep's Signature Phone Number Ins ctor's Signature Phone Number <br /> OC <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: E X AMP 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy L ® ■ <br />