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Waste Tire Su. Bey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1196502 <br /> CalRecycle l8t(Rev.y(Cal Survey <br /> A 6f19/A ®6�Y@fl o pale 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) �3 @J�I 'P9�s Form�Il <br /> P"'*A-Survey BLUE OR BLACK INK PEN <br /> ess Profile Inspection Details <br /> Trip- I � � © � Inspection Type(Fill one) <br /> LA � � � � <br /> Site Suffix: Q Routine Q Re-inspection 9 Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5cky\ V,n Q CHP 40 CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ;-�\, T. �:. 1 1 T <br /> Physical Address - a <br /> Inspection Date / 2 3 / 1 <br /> �.� CPQ q 52oS <br /> Time In Time Out <br /> Business Rep Title (( 9 AM l� 4D AM <br /> S �Cti h� 1 2 0 PM I 4 S 0 PM <br /> �VOf�a✓� Scr�l'u <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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> Cl I& Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> dew Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> V 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 <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 FII / M / <br /> m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXn N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <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 /> \ - z <br /> Comments C\-P— C. o►, on:� <br /> a <br /> i„opection Form Included: Q <br /> Comments Included: Q 7o�`z2f7'73 ��� -_� �o I'�,U�'-32g4 <br /> 4vy <br /> Busines ep's Aignature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: KA IEIXIAIMIPILIEI 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />