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Waste Tire SL. .fey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 11 - 1210443 <br /> CalRecycle 181(Rev. (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- 1 C _ Inspection Type(Fill one) <br /> Site Suffix: d� J ] &Routine Q Re-inspection Q Referral Q Observation <br /> Local , -` If Referral,choose referral type(Fill one) <br /> Identifier: ssell() J o LA-11LA-11!� rW14� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address ` C�C�-Tro <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep <br /> ` Title C5 O AM O AM <br /> a PM �" l/ IV PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) I14 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger .0 Generator A Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude _ Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude _ Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) tw W,1* <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 41 Other VIlAG u!A <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 <br /> 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 <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 ExT) <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 1 Q 1 Other:§ 1 L <br /> CommentsV_e <br /> o Wil nn AA)?A� a <br /> Inspection Form Included: Q u <br /> Comments Included: r ` _ <br /> Business Rep's Sig ure Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: V �jE�XjAjMjPjLjEj 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />