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07J Waste Tire Su. Bey & Inspection Report Inspection Report Number <br /> CalRecycle Reey�e°;o8;(Rev.10/19) 11 - 1230223 <br /> Dept of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � D -3 � a Inspection Type(Fill one) <br /> Site Suffix: I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: , �a v�Y'\ 60,n Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name L Inspected By Inspector <br /> Physical Address v <br /> o o Qs-Cy <br /> CA 9_S 330 Inspection Date I , / 25 <br /> / y <br /> Time In Time Out <br /> Business Rep Title ` O AM O AM <br /> J�'^' QPM � ' � � QPM <br /> I,LQC�I a S Ccs Ct-- MC°`"'S Operational Status Tire Type Business Role Storage Type <br /> Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire <br /> 0 Active Q Passenger 0 Generator Q Outdoor <br /> Q Closed Q Altered Q Hauler Q�tA <br /> G PS Latitude door <br /> p Q Inactive 0 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 • 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 Q § - 0 Notice Of Violation 0 Extension <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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXTJ n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> La <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 /> - Z <br /> Comments � � � ` <br /> _ mems \��ov�P_ cm -N,.,S X1 a <br /> Inspection Form Included: <br /> ?gal <br /> Comments Included: hA/ <br /> u iness ep's Signature Phone Number Inspect is Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: 7X*V E X A M 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C y: ® ■ <br />