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Waste Ore SL__ g & Inspection . _Jpor, 9pection Report Number <br /> CalRecycle State of California I 1 . 1178032 <br /> CalRecycle 181(Rev.y(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: i 5 D 3 -7 5 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local C� If Referral,choose referral type(Fill one) <br /> Identifier ��1 �O�Cc ��- C�t/✓l� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �) Inspected By Inspector <br /> 1/101r� l[. S <br /> Physical Address <br /> 14-700 6j , 5 CAA <br /> / Inspection Date <br /> l Time In Time Out <br /> Business Rep Title n 0 AM 0 AM <br /> Lt'.nv\vDrt✓vteW%_1rs.� l ' o ® PM ( 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 /> Active Q Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> (71PS Latitude Q Hauler ® Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned 4 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <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 a Other � �✓1 V �= t�� <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 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 EXTJ <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 16 In Compliance-No Violations o <br /> Q Q Other:§ <br /> z <br /> Comments <br /> Inspection Form Included: Q4_2 4��z <br /> Comments Included: ® <br /> ss Rep's Signature Phone Number ra9Wt&1s_AQy(ature j Phone Number <br /> INSTRUCTIONS ON BACK [Correct:IS Incorrect: E X A 1112131 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink o E. ® ■ <br />