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Waste Tire SL. ✓ey & Inspection Repoei Inspection Report Number <br /> State of California <br /> CalRecycle11 - 1242231 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> Survey Form - Page I <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � - Q * Inspection Type(Fill one) <br /> Site Suffix: ` 1 Routine Q Re-inspection Q Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SCl V1 �G� V V� O CHP Q CalRecycle 0 Complaint O Educational Visit 0 Other <br /> Business or Facility Name V <br /> Inspected By Inspector <br /> Physical Address <br /> Inspection Date C) 7 <br /> T�CLLY C1� G537� J <br /> Time In Time Out <br /> Business Rep Title _\ 40 AM 1 �n 0 AM <br /> Flo wer ex ��G-''�C 0 PM F Z 1.� e 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 /> 40 Active O Passenger 0 Generator O Outdoor <br /> O 0 Closed O Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned O OTR O End-Use I* Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair 0 Trucking Fleet Q Government Q Retreader 0 Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection O Crumb Rubber <br /> Q Service Station O Hauler Q Agriculture Q Shredder i Other �� �rn <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O 0 PRC§42956-Registration/Decal in Vehicle <br /> O 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> O 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire GeneratorsIS In Compliance-No Violations o <br /> O O Other:§ <br /> Comments�``1n�. �1fxv\p� ��CE+ �,nSf�[•��A`��`�� (kY� �1r:�5 (�1�-�—�11�� <br /> \\ e was <br /> Inspection Form Included: 0 9/ Ori Soo <br /> O <br /> Comments Included: C�J� <br /> Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA <br />