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Waste Tire SL.. Bey & Inspection Repor, -Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1210380 <br /> CalRecycle181(Rev. (ill) 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- r ' \ , - O I Inspection Type(Fill one) <br /> Site Suffix: �j `� * Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SQ,n T�`p t3� ^,coo `/' Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name `"' ' �/ <br /> 1 Inspected By Inspector <br /> orip- <br /> Physical Address^ ' -t � v <br /> ATT <br /> 00 <br /> UO-hQJ-6 Ck SZ�L� Inspection Date S / 2 I 3 <br /> Time In Time Out <br /> Business Rep A Title O AM O AM <br /> C�1f10.t�d.�2 �V,e.r 1 � � � 1111111 PM � O � �PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � <br /> ® Active 0 Passenger &Generator * Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q 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 /> 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 /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / M / m N <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle 3 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <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 Q Other:§ <br /> Comments V1�� ` ��2 ;�5� � (� ^� OVX <br /> f-OJi.lr� ..T � C� <br /> O' S <br /> o� " <br /> \1 zolC'A V GV'S [h �C e a S C �✓�GeS'►�1 <br /> Inspection Form Included: Q 24 <br /> Comments Included: �! - ��--�� <br /> Bu Hess Rep ignature one beV Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E XIAIMI PILIE1 11 12 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA �� <br />