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Waste Tire Su, vey & Inspection Repor ., Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1255958 <br /> CalRecycle (Rev.Recovery <br /> 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- ' O rQ Inspection Type(Fill one) <br /> Site Suffix: V d 1 t� 0 ' * Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �Cl V'._ �GQ�v` ��bh 0 CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> uik)C- TC Iv,cQ _ <br /> Physical Address <br /> 2 5 3B S S• Sc�,�,1 ��. <br /> TC C CA IS377 Inspection Date I Z / 2 S ' S <br /> Time In Time Out <br /> Business Rep Title ' I AM ,+ Q AM <br /> QPM J .QPM <br /> (} �Z_On �2S t��� Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I I O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' I 0 Active Q Passenger 18 Generator 4k Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive Q Truck <br /> Longitude - O Planned 0 OTR O 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 0 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 0 Other t'C��1f`� ��V���(Q [ i <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 /> O 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 /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or Exr) N <br /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations <br /> Q 1 Q 1 Other:§ <br /> Comments 12C. k w-e— -t-'.-ne- V'-SOCCTV4y\ Xovvz C)NfN 4v--S. ��� <br /> OLV.,& 1low�►,c w�� norma <br /> Inspection Form Included: Q � � �j (,� <br /> Comments Included. fi r"✓ 2Oq•'1���-3Zp 0 I <br /> In ep's S gnature Phone Number Inspec is Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS CIV BACK [Correct:0 Incorrect: EXAMPLEj 111213 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />