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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 m 1177960 <br /> CalRecycle cover (Ca[ Survey Fora - 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- u _ © ' Inspection Type(Fill one) <br /> Site Suffix: IS Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: ls Glo Jowq lujn �u� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ` <br /> Inspected By Inspector <br /> i <br /> Physical Address 3 <br /> Inspection Date 9 <br /> Time In Time Out <br /> Business Rep Title 10 AM ` ' AM <br /> 1 xAfne-r l l QPM t QPM <br /> b0 0a,\Ili l���er <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 /> � � � S <br /> 0 Active S Passenger • Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude Q Hauler Indoor <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 /> ( .' New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ® Used Tire Dealer 0 Auto Body 0 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 0 - 0 Notice Of Violation Q Extension <br /> PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / M / m <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 EXT) n <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 /> Lu <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ ____ W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations o <br /> 0 1 0 1 Other:§ <br /> z <br /> Comments V- k` W4 <br /> %- 1 1oc� Am 1 <br /> s luke, cwA �Vy_ <br /> No <br /> Inspection Form Included: 0 , <br /> 20 <br /> Comments Included: <br /> �3 — 8 <br /> Business Rep's Signature Phone Number Ins a tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: NJ E X A 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop E4 <br />