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Waste Tire Su. ,iey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle I 1 - 1196667 <br /> CayclinglRecycle <br /> ndR(Rev.Recovery <br /> Survey Form - 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- Inspection� � � , � � - � Inspection Type(Fill one) <br /> Site Suffix: 7 0 Q Routine 0 Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: So'y\' u;n Vn Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By 1 Inspector <br /> "'V\` 're— I�inG— (n���c'C�o� 5��2 ?) 1 9 - d �"lA-7T-v <br /> Physical Address <br /> 3633 Dvc-V CCetk VC, <br /> Inspection Date I / I ? / I 3 <br /> 6A0y\ C q S 215 9 <br /> Time In Time Out <br /> Business Rep TitleO AM `� O O AM <br /> 15 � PM J 4D PM <br /> G act els `Sp_rc C Mc��n c� <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 /> 0 Active 0 Passenger • Generator Q Outdoor <br /> O Q Closed 0 Altered A/'/ A- <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - O Planned OTR End-Use Q 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 ! Collection Q Crumb Rubber <br /> Q Service Station 0 Hauler Q Agriculture Q Shredder Q Other <br /> .ti <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 /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle i <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •in Compliance-No Violations o <br /> O O Other:§ <br /> Comments 0.V2 o'- %,P— <br /> Inspection Form Included. C) <br /> Comments Included: Q Mai ��t�� s // ""�'—✓�6 <br /> Business Rep's Signature Phone Num r InspectcKs Signature Phone Number <br /> 62081 <br /> . White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA I mm4 ■ <br />