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Waste Tire SL. Bey & Inspection Repon Inspection Report Number <br /> CalRecycle State of California I 1 - 1177799 <br /> CalRecycle 181(Rev.y(CalRecycle) Survey <br /> Sur ey Fo r fhb — Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) �l J �!/�s J ® tl 6f i� C� <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- t Inspection Type(Fill one) <br /> Site Suffix: 3 41 o d 1 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local J-��A� t/1 �t JNI� If Referral,choose referral type(Fill one) <br /> Identifier: _v"� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address :3 I © �r ntil �ti <br /> Inspection Date -7 <br /> btz� _V_Y_\ CA a l C7 / 1 <br /> Time In Time Out <br /> Business Rep Title j C) AM Q)AM <br /> lab Z 0 0 O PM / f � o O PM <br /> flnG Operational Status i Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> G�� Latitude Q Hauler ® Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q 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 <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 /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date mM <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 /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement s <br /> LU <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:§ <br /> Comments <br /> V <br /> Inspection Form Included: O <br /> Comments Included: ® s <br /> Business Rep's 61`gnatu A Phone Number _(- nspwtorigq6ture Phone Number <br /> INSTRUCTIONS ON BACK I Correct:0 Incorrect: E X A L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co ® ■ <br />