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Waste Tire ;,'key & Inspection Repopection Report Number ■ <br /> p <br /> CalRecycle State c California I 1 - 1226667 <br /> CalRecycle181 dR(Rev. y(Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A-Survey - — --- _- <br /> Business Profile Inspection Details <br /> TPID- L - I Inspection Type(Fill one) <br /> Site Suffix. d "� ' O ` * Routine Q Re-inspection Q Referral Q Observation <br /> Local �\ / ,,-• If Referral,choose referral type(Fill one) <br /> Identifier: `1n vv� � ��� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> `C LAS iv�(9 J C)� C1ts 5 - 7 /l <br /> Physical Addre C� ES140 <br /> �C55 N � 'VVA5or) W <br /> Inspection Date l I � I S / k 1 <br /> �fvoc l2ka n Sa Time In l Time Out <br /> Business Rep Title0 AMI . O 5 ® PM ` AM <br /> I PM <br /> La►(A mu�� �r <br /> Operational Status Tire Type Business Role Storage Type <br /> (_ (`J (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) �(1 0 ® Active Q Passenger ® Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> p Q Inactive Q Truck <br /> Longitude - Q Planned ® 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 ® Other mv6J(, '`z -sQOA S <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / M / M <br /> N <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 — (Required for NOV or EX7) N <br /> CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q Q Referred/CalRecycle Enforcement <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Lu <br /> Lu <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _- <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> ,0 , 0 Other:§ 1 ,,``-- 1 L <br /> Comments lLU t V�U�4�t kion c),,pru on ��Yll� CR�(��"� G,ntAbnz <br /> �6 S n OWN <br /> Inspection Form Included: Q 1 i� 1� Ll S <br /> Comments Included: ®- <br /> Business Rep's Signature Phone Number $JsptorrlsS�ig�nCre Phone Number_ <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X AL 1 2 3 ■ <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co y:LE <br /> ■ <br />