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Waste Tire SL. .fey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1242437 <br /> CalRecycle (Rev.y(CO) 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- Inspection� 1 � � � � ® ` Inspection Type(Fill one) <br /> Site Suffix: 1 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S4� V�N1 00Qy\, 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name / Inspected By Inspector <br /> Sc-,8Ae.;4E -e �;c-es�dv�t LSC. 3 _ ® �T�' <br /> Physical A ress <br /> 'l 20 tE. v�nw�6 � �n Al� <br /> Inspection Date D 7 O -7 1 <br /> Time In Time Out <br /> Business Rep Title y O AM O AM <br /> e ' 1 PM ® PM <br /> 't Ore Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) U L (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> -{ V 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 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 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) 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 0 i Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments dl �(1wme— clY\ <br /> n.jA_ �G.2 <br /> ZCA- <br /> Inspection Form Included: 0 <br /> Comments Included: AInspec <br /> ��(Business Rep's Signa Phone Number ro's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct: Incorrect: IEIXIAIMIPILIEI 1112L3] 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />