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Waste Tire fey & Inspection Repo Inspection Report Number <br /> Mmyae State of California1R I 1 - 1226501 <br /> CalRecg and R(Rev.y(Gai Survey Form - Page 1 <br /> Dept of Resources Recycling and Recovery(talRecycle) <br /> Part A_SUn Ie fL _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: �^^�� <br /> CJS � 6 0 1&Routine Q Re-inspection Q Referral Q Observation <br /> l <br /> Local �^ If Referral,choose referral <br /> Identifier. ��iri��� C� /1/� A type(Fill one) <br /> _- Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> IAZ-a.L kerb <br /> Physical Address <br /> Inspection Date 5 <br /> Time In Time Out <br /> Business Rep Title Q AM <br /> O AM <br /> -® PM -- Q ®PM <br /> Operational Status Tire Type Business Role Storage Type I <br /> (Fill one only) (FII all that apply) (FII all that apply) (FII all that 1 <br /> Tire Count(Whole/PTE) --7 O apply) <br /> 0 Active ® Passenger Q Generator 4& Outdoor <br /> Latitude Q Closed Q Altered <br /> GPS 40 Hauler Q Indoor <br /> Longitude <br /> C Q.Inactive ®Truck <br /> - <br /> {-- Q Planned Q OTR Q End-Use ® Container ; <br /> Business Type(Fill all that apply) •-- <br /> rQ New Tire Dealer Q Flee <br /> Auto Repair Q Trucking t Q Govemment Q Retreader Q Dismantler Q The Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station ® Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility I ENFORCEMENT STATUS _ <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of violation Q Extension <br /> 'Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> 0 Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 orEX7) ; <br /> Q 1 Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years —"- ---- - - <br /> Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers ®Referred/CalRecycle Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators in Compliance-No Violations <br /> 010 Other.§ <br /> Comments - - - - - - -- - <br /> Act <br /> ' Inspection Form Included: Q <br /> Comments Included: Business Rep s Signature Phone Number o <br /> s gnature Phone Number <br /> INSTRUCTIONS ON BACK Correc • Incorrect: 62081 <br /> � � � �1 EXAMP L E 1 2 3 <br /> White Copy: aIR 'yc Yellow Copy:Operator Pink Copy:LEA <br />