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Tire le Ins Re orpinspection Report Number <br /> Waste e S y & Inspection p p � <br /> CalRecycle State of California 11 - 1242056 <br /> CalRecg and R(Rev. y(Ca)' 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- I _7 79 I Z _ O 1 Inspection Type(Fill one) <br /> Site Suffix: 10 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��y% OCtO�V�Y\ C0% Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> vo�ks wooer 5 �.�� q _ o T v <br /> Physical Address M A� <br /> Inspection Date O 5 <br /> S'C�C�TdY1 �S2`� Time In Time Out <br /> Business Rep Title O AM f O AM <br /> l� .e• _ �j� &PM 1 PM <br /> 4�1Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> V 0 Active 10 Passenger 40 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> 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 0 Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q 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 /> 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 /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> v <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments �; �� \ _ <br /> � o����-���s�c 'ice ��S�e.�-�.� �c���c� S <br /> �� g s�LV-4n <br /> c <br /> Inspection Form Included: Q <br /> Comments Included: <br /> m <br /> B ess R s p' Ignature Phone Number Inspect is Signature Phone Number <br /> zX W �( 62081 <br /> INSTRUCTIONS ON BACK [Correct: Incorrect: �/ E X A'M P I L I E 1 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />