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Waste Tire SL. Bey & Inspection Reporl9lnspection Report Number <br />State of California <br />CalRecycle 11 -1255733 <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 Prof ife <br />O <br />Inspection Details <br />O <br />TPID -C <br />Site Suffix: 5 <br />` <br />J - Q 1 <br />Inspection Type (Fill one) <br />O <br />PRC § 42956 - Registration/Decal in Vehicle <br />O <br />* Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />O CHP O CalRecycle Q Complaint Q Educational Visit O Other <br />Local/ <br />Identifier: 50.r TG V" <br />Business or Facility Name <br />Co����� C� <br />Inspected By Inspector <br />O <br />` <br />CO( <br />Physical Address <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />^'\\ <br />O <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />L_ <br />V100 <br />Inspection Date <br />Time In <br />Time Out <br />Business Rep <br />Title <br />0 AM <br />I ' 2 <br />0 AM <br />© <br />[�� 1 <br />a� \ 1-W.�"i�h <br />C. <br />oPM <br />0 PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) <br />6 <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />• Active <br />Q Closed <br />Q Passenger <br />Q Altered <br />* Generator <br />Q Hauler <br />* Outdoor2— <br />10 Indoory C) <br />O <br />GPS Latitude <br />O <br />Q Inactive <br />® Truck <br />Longitude - <br />Q Planned <br />Q OTR <br />O End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair <br />Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer Q Auto Body <br />Q Car Dealer Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler <br />Q Agriculture Q Shredder Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V F A-1 HAULING AND MANIFEST REQUIREMENTS <br />O <br />O <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />O <br />O <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />O <br />O <br />PRC § 42956 - Registration/Decal in Vehicle <br />O <br />O <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />O <br />O <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />O <br />O <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />O <br />O <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />O <br />O <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />O <br />O <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />O <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />O <br />O <br />Other: § <br />Comments <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EX7) <br />O Referred / CalRecycle Enforcement <br />0 In Compliance - No Violations <br />o ` 001. !c mea S ea_� Cov-Cef A <br />Inspection Form Included: Q �%f 7 ((1 <br />Comments Included: <br />usines Rep's Signature Phone Number Inspe or's Signature Phone Number <br />62081 <br />INSTRUCTIONS ON BACK Correct: 0 Incorrect: X Ej X A M P L E 1 2 3 <br />■ White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA © ■ <br />0 <br />