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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1230346 <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- � _ © � Inspection Type(Fill one) <br /> Site Suffix: 1 U J 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �, If Referral,choose referral type(Fill one) <br /> Identifier: cAn \"L& C0101i A 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name � "� <br /> Inspected By Inspector <br /> Physical Address L 1 CQ-�'� <br /> ly� (� <br /> Inspection Date <br /> _}"o l�o„ CA ClS Z.l L <br /> Time In Time Out <br /> Business Rep Title l • AM I l ® AM <br /> p 1 l O 3 () 0PM t i 0P <br /> - -d— - Operational Statgs 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 0 Generator 0 Outdoor <br /> O • Closed 0 Ald-44�4 0 Ill 0 �iq <br /> GPS Latitude Haulel'� Indoo <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> i 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 ®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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> PRC 42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 § 9 Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 EX ) 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 /> W <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations o <br /> 0 0 Other:§ y II'' � t 1 -_ <br /> Comments n u,kAA1�wu4c.. 1'S�1r5( t�CY� ���t (�qs VL17���� �U!'l7 m'1 I IAIh& naTc�� <br /> 1W 1J e U iU��"i( <br /> 'r 5 Jet�.0 �1nls 10(.a�1t l8�'�)Cai C�USe,t 'S ���D_ <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> ep's Signature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS OWBACK Correct:0 Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA ® ■ <br />