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Waste Tire &_ rey & Inspection Repon Inspection Report Number ■ <br /> Cal Recycle State of California I 1 - 1177893 <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- 5 0 D Inspection Type(Fill one) <br /> Site Suffix: I* Routine Q Re-inspection Q Referral Q Observation <br /> Locale If Referral,choose referral type(Fill one) <br /> Identifier: S -Cf) J Octui.� u� � Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address �6 C7Yoft) <br /> Inspection Date I 0 / o ' I / l j,� L`'Lkp� Cit �Sws v "I <br /> Time In Time Out <br /> Business Rep (� Title j : Q 5 O AM r 0 AM <br /> 1�1A {� ' " '�1`1 \fo�UC�lcv� - 0 PM `f S PM <br /> Operational Status Tire-Type Business Role Storage Type <br /> Tire Count (Whole/PTE) ()7( (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> SCJ ® Active Q Passenger 41 Generator Q Outdoor <br /> O Q Closed Q Altered N A <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) Flus <br /> Q 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 10 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 /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 E)C7) n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years c <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators .In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments Ve- a. N <br /> Inspection Form Included: / <br /> Comments Included: 7/ ` <br /> 136-16s Rep' Sig ature Phone Number Inspe t is Signature Phone Number <br /> INSTRUCTIONS ON BACK I Cor :0 Incorrect: )( � 9fEXAM 1 2 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy.L ® ■ <br />