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Waste Tire SL.. Bey & Inspection Repori,, Inspection Report-Number <br /> State of California <br /> CalRecycle I 1 - 1230441 <br /> CalRecycle 181 cover (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- � 1 Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local (�� If Referral,choose referral type(Fill one) <br /> Identifier: Y\ `LlV Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> � oaI�1r.�o 'Devi acid to - 9 _ c3 1 /�,� V <br /> Physical ddress ` 1 <br /> 769 Z s. <br /> Inspection Date <br /> S�Oc�-�-d,n CN QIS2c� <br /> Time In� Time Out <br /> Business Rep Title � � `` � O AM � � � O AM <br /> PM A 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 /> o • Active i Passenger 0 Generator Q Outdoor <br /> Latitude Q Closed Q Altered AGPS 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) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 0 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 I* Other h"Ceo V <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 EXT) N <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 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 <br /> SZa. �•.e �a�s� �:ce :v.Sp ec 3�h c�.c�nQ o v� -_� mak— p � <br /> :ouch d -0-6'h <br /> Inspection Form Included: Q <br /> Comments Included: — ���✓�D�/ ` ��_ "�� <br /> Busin s Rep's Signature Phone Number Inspecto s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: jEjXjAjM� PjLjEj 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />