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Waste Tire jurvey & InspecUan Repu, t Inspection Report Number <br /> CalRecycle State of California11 - 1245380 2 4 5 3 8 <br /> CalRecycle 181 Recovery <br /> (Ca[ S 91Y9.11e y Form - Page I 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) Survey V J G <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I ^ 4 1 - Inspection Type(Fill one) <br /> Site Suffix: z (0 c) 1 40 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> LAS Sc,h kx�-� 7j <br /> Physical Address <br /> � <br /> Cad IS-33 Inspection Date 0 / p (p <br /> Time In Time Out <br /> Business Rep Title 0 AM z : Q AM <br /> 2 �1 pl C.��r� nnQz✓lOQ_.,C,(�. I I • 133 QPM � �PM <br /> o Operational Status Tire Type Business Role Storage Type <br /> Tire Count /PTE) -0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> T9J $Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive Q Truck <br /> Longitude - End-Use Container <br /> 0 Planned 0 OTR <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 40 Used.Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation � Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / FTI <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> a <br /> n <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> f <br /> W <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments �� � �i{�1 C/� � it "�"✓ _ N <br /> �rL <br /> Inspection Form Included: 0 <br /> Comments Included: 46 <br /> Bu ss Rep's Signature Phone Number Inspec or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAMPLE 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />