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Waste Tire Sley & Inspection Repor ,, Inspection Report Number <br /> CalRecycle State of California 11 - 1242474 <br /> CalRecycle (Rev. (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling anddRecovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 ,7 lj � � � , f - Q l Inspection Type(Fill one) <br /> Site Suffix: `� Is Routine Q Re-inspection Q Referral Q Observation <br /> Local �� 1 CIf Referral,choose referral type(Fill one) <br /> Identifier: S,u� J o C9 u1 n LDun-1 0 CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name L, <br /> Inspected By Inspector <br /> ArA()n�nI' Cn�cr �rtSes L LL <br /> Physical Address 3 - 1 G I CIS -TO <br /> � Inspection Date / t 4 / 1 y <br /> Time In Time Out <br /> Busine,O p S Tit / Q AM r� Q AMm�s� V ®PM CO 0 PM <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 /> • Active Q Passenger 0 Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler V Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 Q 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 /> Q Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O 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 m / m / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <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 /> 010 Other:§ <br /> Comments � l <br /> c� l W u 3�c��TA'�I�,n5 � � o� S �l�j"c_ �Cl U1 <br /> --Srj \1�-k-k)Ir= A)CA S <br /> No V10 A�mS�OS u,Je��- r �nCern_ <br /> Inspection Form Included: <br /> Comments Included: Z' <br /> jBiess Rep's Signature Phone Number In ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P L EJ_j 112 3 1 <br /> 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: <br />