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Waste Tire Sul. ✓ey & Inspection Report inspection Report Number <br /> CalRecycle State of California r�� 11. - 1177995 <br /> CalRecycle l and <br /> Recoveryv. <br /> (10) Survey Foam - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) VV <br /> Part A-Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ,w n O ( Inspection Type(Fill one) <br /> Site Suffix: 1 17 <br /> lY `� 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalI If Referral,choose referral type(Fill one) <br /> Identifier: 0 _J64A Gln Q CHP Q CalRecycle 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> (ve-0s�' l�ustn � , � 0 3 <br /> Physical Address ES CV� <br /> ,1 G Inspection Date <br /> Time In Time Out <br /> BusinessRepTitle ® AM� ®AM <br /> //��O PM � V I � O PM <br /> OLID llcf <br /> - - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I Zj <br /> ® Active Q Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q 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 /> 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 /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Uj <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 <br /> in Compliance-No Violations o <br /> Q 1 Q Other:§ <br /> Comments i2-ou���. u7���r �I"t�Tc �1�J�{On /�,U� �S� ��'1�5��`� d►1�l r '-� <br /> SCO 1�p W" <br /> b t � 0� C.�IcUS 0� C0�1 Cern' <br /> I Inspection Form Included: O <br /> Comments Included: <br /> Business ews signature Phone Number Insp or-s Signature Phone Number <br /> INSTRUCTIONS ON BACK rrect:* Incorrect: E X A M P L E 1 2 3 62081 <br /> Co <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L ® ■ <br />