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Waste Tire Su. Jey & Inspection Report Inspection Report Number <br /> CalRecycle State of CalRecycle <br /> (R I 1 - 1242172 <br /> Caycling ndRec very(10) Survey Form v Page I <br /> Dept.of Resources Recycling and Recovery(CalRecycle) survey� 1r Page <br /> Part A-Survey _ BLU__E OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ^ ,` _ 1 Inspection Type(Fill one) <br /> Site Suffix: `'� `� *Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �'oc �� V� ./ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name / <br /> Inspected By Inspector <br /> Physical Addressss 39 <br /> - <br /> �OC)C) S• ��cocc� s�. - - <br /> S� Inspection Date b -7gS2c6 ' . l� <br /> Time In Time Out <br /> Business Rep TitleO AM O AM <br /> �2CCc�vs 5> 40 PM ® PM <br /> V\vcco N\CkS*-n<2- - <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 /> � Z, <br /> 00 Active Passenger 4k Generator 49 Outdoor <br /> O Q Closed Q Altered <br /> GPS Loma"' Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type '--il aif L'tat apply) <br /> Q New Two Db+w 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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other <br /> Part B-Inspetftn of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULJNG AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 M / M / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <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 •In Compliance-No Violations o <br /> Q Q Other: - <br /> Comments �Y�Q-- ll��- �'R' '� � �\•�_ �� ��.� �`� E�.�Ir1�, <br /> � tx.� •C5C e <br /> Inspection Form Included: O <br /> Comments Inc luded: <br /> Business Rep's gt 'snat a Phone Number InspecSignature Phone Number <br /> INSTRUCTIONS �ON BACK Correct: Incorrect: NJ E X A M P L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />