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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 11 - 1210462 <br /> Ccyclin and le 181 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- ' C ® ( _ 0 ) Inspection Type(Fill one) <br /> Site Suffix: J �Q t 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local o If Referral,choose referral type(Fill one) <br /> Identifier. 5 oJ (J(�Cf U ((�t,t Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Namepp l 11 Inspected By Inspector <br /> \ <br /> (�e L f �J�-Vl�f's i e_S 2l Cs CC7�T <br /> Physical Address J � - � l� / Yj <br /> Inspection Date <br /> 01P C A <br /> Time In Time Out <br /> Business Rep Title1 ® AM I 0 AM S <br /> Scc� 5�,�� n Ods_ C'tl T, <br /> O PM • 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 ® Generator Q Outdoor <br /> o Q Closed Q Altered II <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q 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 Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other 04_r)'WLvl G'nrcr <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 /> Q Q 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 N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> a <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 <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q 1 Q 1Other:§ - - -- <br /> Comments >Q_U'I 'AA ,t A Jfd �rC, )I 11'S -r\ 4WSmid N <br /> IN .0 1, 01w '(JAS '0s u recto 1)(n- <br /> Inspection <br /> � ,�ncQrn <br /> Inspection Form Included: Q q 0 <br /> Comments Included: I& d <br /> Business Rep's Signature Phone Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: >� EXAM L, 1112131 <br /> 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co :L <br />