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Waste Tire Su%e & Inspection Report inspection Report Number <br />CalRecycle ev. y p - ■ <br />State of California I 1 12 5 5 8 4 4 <br />CalRecycle cover (CalRecycle)Survey <br />Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />A BLUE OR BLACK INK PEN <br />-z— <br />Business Profile <br />Inspection Details <br />TPID - <br />I S <br />Inspection Type (Fill one) <br />Site Suffix: <br />i Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Local <br />Identifier: 5'Y1 G V r Co * <br />Business or Facility Name <br />Inspected By Inspector <br />d dress <br />Physical Ad <br />`5337 <br />Inspection Date 3 Q ' <br />Out <br />` <br />Time In Time <br />Business Rep Title <br />C O AM O AM <br />I�,, [ <br />l "� uweA 0W <br />.7 0 PM WPM <br />Operational Status <br />(Fill one only) <br />Tire Type <br />(Fill all that apply) <br />Business Role <br />(Fill all that apply) <br />Storage Type <br />(Fill all that apply) <br />a0.A�d-\ e—� <br />Tire Count (Whole/PTE) <br />51 <br />0 Active <br />Q Closed <br />0 Passenger <br />Q Altered <br />• Generator <br />40 Hauler <br />0 Outdoor <br />Q Indoor <br />GPS Latitude <br />Q Inactive <br />Q Truck <br />O <br />Longitude – <br />Q Planned <br />Q OTR <br />0 End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />4& 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 0 Hauler Q Agriculture Q Shredder Q Other <br />Part <br />B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />V <br />T A <br />HAULING AND MANIFEST REQUIREMENTS <br />Q <br />Q <br />C § 42951 Waste Tire Hauler Registration and Transport of Tires <br />PR - <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />(Required for NOV or EXTJ <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q Referred / CalRecycle Enforcement <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />• In Compliance - No Violations <br />Q <br />Q <br />Other: § <br />Comments <br />VO `ln� <br />Q <br />�b wi0r­5 Wes VVS <br />G`cZCL_ a�7 Gphce`ryaS Cin Coc-y - <br />Nos <br />.c n <br />Inspection Form Included: Q <br />QLCPtLhj � <br />Commentslncluded:111111, <br />R� <br />ne Number <br />PQho�nNumber Inspe toyys Signature o <br />INSTRUCTIONS ON BACK <br />Correct: 0 Incorrect: <br />EXAMPLE <br />1112 <br />3 <br />62081 <br />- White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA <br />■ <br />