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Waste Tire Su. ✓ey & Inspection Report <br /> Inspection Report Number <br /> Cdecycle State of California 11 - 1210138 <br /> CalRecycle cover (CalRecycle) Survey <br /> Survey Farm - 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 5 � O � � - � � Inspection Type(Fill one) <br /> ` <br /> Site Suffix: 7 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ,^ �vQa V Gh Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Businessbr Facility Name 1 Inspected By Inspector <br /> W - 1 0 <br /> Physical Address <br /> '50 �I <br /> Inspection Date 8 / C) 7 / 1 3 <br /> Ccis3o`1 <br /> Time In Time Out <br /> Business Rep Title AM h e AM <br /> ©C-2,� ©W` V�2 ` O Q PM . O v 0 PM <br /> ell Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 1 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' 1 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> o Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer 0 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 <br /> Part B - Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS 7 <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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 EX7) 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 <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business ep's ignature Phone Number Insp ctor's Signature Phone Number <br /> �-,( <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: g EXAMPLE 1112 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />