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'a Waste Tire SL.. dey & Inspection Repon Inspection Report Number <br /> CalRecycle State of Californiaev.10110) S /(� m P 1 11 - 1210397 <br /> Dept.of Resources Recycling and Recovery ery(CalRecycle) Su• v`may For°°" — • age ° <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � n � � _ O � Inspection Type(Fill one) <br /> Site Suffix: L I*Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sah To-al v ^ v v��� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` -- <br /> Inspected By Inspector <br /> Les 6 vim" 6 7 7 3 � - ( 0 l �ATT U <br /> Physical A dress <br /> Tov<- 1Z�- <br /> CJN 9 ��� Inspection Date S / / ' 3 <br /> �� Time In Time Out <br /> Business Rep Title ® AM ® AM <br /> U O S Q PM 00 O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Wholet, L (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I (� 0 Active 0 Passenger *Generator Q Outdoor <br /> o Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive a Truck <br /> Longitude - Q Planned Q OTR Q End-Use • Container <br /> Business Type(Fill all that apply) <br /> 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 Q 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 m / Ffl / 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 EX7) N <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <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 Q1 Other:§ <br /> z <br /> Comments <br /> l CoA' <br /> \ <br /> Inspection Form Included: Q Zg <br /> Comments Included: <br /> Busin s Rep's nature Phone Number Inspe tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:11111 Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA ® 0 <br />