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Waste Tire Arvey & Ins ection Re orip Inspection Report Number <br /> CalRec cle State of California <br /> Y CalRecycle Recovery <br /> y(Cal Survey Form - Page 1 I1 - 1244904 <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 n, O I Inspection Type(Fill one) <br /> Site Suffix: `� / Routine Q Re-inspection Q Referral Q Observation <br /> Local /n� If Referral,choose referral type(Fill one) <br /> Identifier: S 1 ' J 04 t;1 n n 0(V�N Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> ��fc,�'�uw{CS' l <br /> Physical Address 3 J I C TTo <br /> Inspection Date 1"f / r_ / ` S <br /> �otA� C� �S�.�t.o <br /> Time In Time Out <br /> Business Rep Title I 5 S :PM M � � o 0 AM <br /> �PM <br /> UNA 5 Atun►� (yw�1c!- <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 /> ® Active O Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude ® Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use • Container <br /> Business Type(Fill all that apply) <br /> Q 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 Q Car Dealer Q Collection Q Crumb Rubber c <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other rnble.�)1e Sa4s <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 <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 EXE N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> i; <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 <br /> In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments (�tJ1li 1C "�l�(t✓1 n lY1 [9n �t S <br /> y <br /> Inspection Form Included: Q <br /> Comments Included: 4 — rf <br /> Business Rep's Signature Phone Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: E X A MIP E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L <br />