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Waste Tire SL. rey & Inspection Report 'Inspection Report Number ■ <br /> CalRecycle Sate of California 11 - 1230382 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> Survey Form - Page 1- <br /> Part A- SuryDept of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> ey - _ <br /> Business Profile Inspection Details <br /> TPID- � � � � � � � Q ' Inspection Type(Fill one) <br /> Site Suffix: &Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SG-y\ J�C,,Ql v�n C0�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical!2ese_ 9 <br /> Inspection Date o G / l 'S 1 <br /> ►�-cQ�c1�, �o�r.e �' X5231 1 <br /> Time In Time Out <br /> Business Rep Title �7 O AM O AM <br /> L S 0P ®PM <br /> fi N7A' Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <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 O 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 <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 Ex7) n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years 8 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> W <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 YW. a' <br /> �tt�'+ t�v. .2. �9�.5�{, e�-�t�2_, �v►��'Cb r���c\P -�?� '�`3 �'Cc.- Q�nc�. 'Ch P �, <br /> Inspection Form Included: Q J# A Z 94*4V11 <br /> 4—V48-32. 1U <br /> Comments Included: <br /> usinessEqeqpature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: K*Y]JE�XjAjMjPjLjEj 11 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />