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Waste Tire SL. jey & Inspection Report .Inspection Report Number <br /> CalRecycle State of California 11 - 1230187 <br /> CalRecycle 181(Rev. (cal 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- � Inspection Type(Fill one) <br /> Site Suffix: *Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �dn.A �t Cz V�- 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 0 Inspected By Inspector <br /> Physical Address <br /> Inspection Date � k / 0 / <br /> ( �K Time In Time Ou"tt✓✓✓ <br /> Business Rep Title IO *0 AM 1 *0 AM <br /> ^_ QPM z 11 QPM <br /> V,GS Itc¢ 1 SSS Operational Status Tire Type Business Role Storage type <br /> Tire Count (WholPT / / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 2 <br /> 6 6 0 Active 40 Passenger * Generator 4@111 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive Truck <br /> Longitude - 0 Planned OTR 0 End-Use f, 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 , 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 /> Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / <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 EXE 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 /> w <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> 0 1 O Other:§ <br /> Commentsspprk��%-% ko" (3 Y% <br /> I�— <br /> �'c�v <br /> Inspection Form Included: 0 <br /> Comments Included: O�?J4o <br /> Busi ep's Signature Phone Number Inspector's 6ignaiure Phone Number <br /> INSTRUCTIONS ON BACK Correct:ID Incorrect: 7X7*_V]jEjXjAjMjPjLjEj1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® . <br />