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Waste Tire SL. Bey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle 10/10) <br /> I 1 - 1242513 <br /> CalRecycle (Rev.Recovery <br /> 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- ' ( C D Inspection Type(Fill one) <br /> Site Suffix: l J 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �1 If Referral,choose referral type(Fill one) <br /> Identifier: S-t4 J O QA 14;'-N 0-04n') 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By 1 Inspector <br /> Physicalal Ad <br /> Address <br /> So SID Cris P a.n�-er - <br /> Llb(Oti\41)Ln CA G1 SvS Inspection Date <br /> Time In Time Out <br /> Business40 TRep n Title y �-• 0 AM 0 AM <br /> `J C�C'.t tlJl �D'lrs S�1 � J ® PM � � � � PM <br /> L�191- <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 Is Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> D 0 Inactive I* Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair ® Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 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 A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <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 /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> f <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <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:§ T1;11 11- ��' �A <br /> Comments `�-U�'Ql�'Q� WuSe. `'!� f��O1�Or � J r lla� al�e_ A ► �s— <br /> __ d(Ao w x n 4 Vous Paw , <br /> N)O vj0j JA�'D/)5 O1 c JP_14_S <br /> Inspection Form Included: 0 , p <br /> Comments Included: ® Z69_g`/U <br /> ' <br /> Busess Rep's Signa a Phone Number Insp is Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct:' <br /> Incorrect: E X A M E 11213 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: E <br />