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Waste Tire SAS#& Inspection Reporal0ection Report Number <br /> State of <br /> Calftcyl{ a CalRecycle 1181nia(Rev.10/10) — <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> ur§ey Fora - Page 1 I1 1210548 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- o © � Inspection Type(Fill one) <br /> Site Suffix: • Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local 1 . If Referral,choose referral type(Fill one) <br /> Identifier: scu, 7QQj l'ir, 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address � <br /> 36C>0 %�c®*c V—&. <br /> 15 9S21-5 Inspection Date / � / 1 <br /> ��� �� Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> Z S 0 P 0 0 P <br /> CCA voc So VA � �� 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 /> 9J 0 Active 0 Passenger Generator 0 Outdoor <br /> O 0 Closed 0 Altered N/A- <br /> cps Latitude 0 Hauler 0 Indoor <br /> O 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 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 I. Other 6�V��� Co <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 <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> N <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities m <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:§ <br /> r� <br /> Comments <br /> �oMA5) ( N QS CC:wC2�Y'\ <br /> Inspection Form Included: 0 =a' �{ ( 2 p. <br /> Comments Included: "�1 <br /> Busin"R,,Signature Phone Number Inspe tot's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EIXIAIMIPILIE1 1112 N 62081 <br /> MWhite Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />