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Waste Tire SAey & Inspection Reportnspection Report Number <br /> CalRecycle State of California I 1 - 1230,102 <br /> CalRecycle cover (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- /^ b 3--� _ O f Inspection Type(Fill one) <br /> 9 <br /> Site Suffix: I 1 40 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local e-T, I If Referral,choose referral type(Fill one) <br /> Identifier: -eA(\ J Oa-��' -) cvur • � 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name `J Inspected By Inspector <br /> (� + 0 Cvn -s 1Aj,0--, 39 - 1 01 CszOT70 <br /> Physical Address <br /> le . m)mj- Ave__ <br /> Ito <br /> 1J4�r'�[,Sj[�.O^ (A %:a05 Inspection Date <br /> Time In Time Out <br /> Business Rep Title <br /> ^^ + 0 0 ® AM O 16 AM <br /> 3 O PM � QPM <br /> 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 /> 0 Active 0 Passenger ® Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O 0 Inactive ® Truck <br /> Longitude - 0 Planned ® 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 Q Other CO3n4j <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PR - Q Notice Of Violation Q Extension <br /> C§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 m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> a <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <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 ®In Compliance-No Violations o <br /> 0 0 Other:§ j. f l <br /> Comments �c\��1C1t L/UOIS�Z 1Je�lUf1 �� I� �ilYl� oI6U��i1�1_ <br /> Gens 41 <br /> n a <br /> Ne) -V'106i Ns rw cAfVA's Q�UJ Q r'n. <br /> Inspection Form Included: 0 t � 6�p��0✓e <br /> Gq <br /> Comments Included: 0—f <br /> �ZO � _���b <br /> Business p's Signature Phone Number Insp tor's Signature Phone Number <br /> �,{ <br /> INSTRUCTIONS ON BACK Correct: Incorrect: , w �J E X A MP L E 62081 <br /> 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop L <br />