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Waste Tire Su. ,iey & Inspection Repon inspection Report Number <br /> CalRecycle State of California I 1 m 1177900 <br /> CalRecycle (Rev.Recovery <br /> Survey Fora v 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- � n C� _ O I Inspection Type(Fill one) <br /> Site Suffix: / 0 ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalC ` \ If Referral,choose referral type(Fill one) <br /> Identifier: Sale VG�1'�141, <br /> n (DAn�Jv 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business r Facility Name Inspected By Inspector <br /> `��� )'S o�w l CD . _ <br /> Physical Address fJ <br /> C ( 3 Inspection Date / 5 / l <br /> CGL J <br /> Time In Time Out <br /> Business Rep r Tittle- , o U O AM z AM <br /> 1 2 _ CJ SrID c ® PM 3 V ® PM <br /> ICI, `� ,� 1 Vlcr�►h.�. <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) Ae (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> )o ® Active 0 Passenger 0 Generator 0 Outdoor <br /> �� <br /> 0 0 Closed ® Altered 0/ <br /> GPS Latitude ® Hauler 0 Indoor <br /> O 0 Inactive e Truck <br /> Longitude — 0 Planned ® OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 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 0 Car Dealer ® Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® 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 /> 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 <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 /> 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 ®In Compliance-No Violations <br /> 0 0 Other:§ <br /> Comments eo,&�; 1 ) ^ AD.Aj ) <br /> f N <br /> 7'1 <br /> of lc,r�S CUA Ceram. <br /> Inspection Form Included: 0 <br /> Comments Included: ® 7 u <br /> BusineKs Re 's SignAture Phone Number Inspec s Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct: Incorrect: E X A P 11213 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink C y: A <br />