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Waste Tire Sui vey & Inspection Report Inspection Report Number <br /> CalRecycle State of California ppp��� 11 - 1177991 <br /> CalRecycle (Rev.Recovery <br /> Survey Form — Page I <br /> Dept.of Resources Recycling and Recovery(CalRecycle) V tl C'9 J E 0� <br /> Part A- Survey BLUE OR BLACK INK PEN_ <br /> Business ProfileInspection Details <br /> _ I <br /> TPID- i _ /n Inspection Type(Fill one) <br /> Site Suffix: V * Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local e - 1 If Referral,choose referral type(Fill one) <br /> Identifier: (� J 0 C1 Lk 1r\ bid 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> ���1 Inspected By Inspector <br /> S',fy,r 19 <br /> Physical Address <br /> ( 000 S _ Aucofc� S- ' <br /> �S�l Inspection Date b S 1 a <br /> L� U Time In Time Out <br /> Business RepTitleI O AM O AM <br /> � ( I,j6K_)6k , 0 )S_ 0PM U ® PM <br /> 'J Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active 0 Passenger • Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 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 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 I A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 - �Notice Of Violation � 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 /> 0 0 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 a <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT <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 /> 2 <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ u, <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments 10 0 <br /> No V�oda inns �s c�,Scc,�s c�' on mf f) . <br /> Inspection Form Included: 0 <br /> L-1Gg- 1'1 <br /> Comments Included: <br /> mess Rep's Signat a Phone Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:I* Incorrect: �j E X AM _ JLJEJ 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co :L ® ■ <br />