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Waste Tire Su,vey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1196559 <br /> Ccyclin and le 181 <br /> (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 /> Site - "1 2 q � n 2 _ O t Inspection Type(Fill one) <br /> Site Suffix: 7 "� ?S ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier ''�` ` \\ - <br /> 0.h V OQ�V 1`t'� �j t��'�f 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name // Inspected By Inspector <br /> 'DS W'\'C' o <br /> Physical Address cA <br /> 011A �Ac\ cw\ CjL_�13 e- <br /> ! "—X`;eC� CA '�S3 37 Inspection Date 0 1 / C) -7 <br /> Time In Time Out <br /> Business Rep Title13O AM kA ✓C O AM PM <br /> C7�� PM I � <br /> CcsO['ee Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active 0 Passenger 0 Generator 0 l`Outdoor <br /> O 0Closed 0 Altered N 1A <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 40Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> O 0 - 0 Notice Of Violation 0 Extension <br /> PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> Uj <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations o <br /> 1010 1 Other:§ <br /> Comments <br /> Inspection Form Included: 0 eA <br /> Comments Included: �� � ! <br /> sines.Rep's Signature Phone NumbneZZinspectofls Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P L E I 1T2]3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />