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Waste Tire ey & Inspection Repor nspection Report Number <br /> Cal RSC cle State of California <br /> Y CalRecycle (Rev.Recovery <br /> Survey Form - Page 1 I1 - 1226300 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 3 a _ Inspection Type(Fill one) <br /> Site Suffix: a ( 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> �►"Z`"12�TS _ I <br /> Physical Adc�t3ess ( [ f3o�_l2-!/ <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 t 0 0P o� ® ® 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 /> 0 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> PS Latitude <br /> o 0 Closed 0 Altered Indoor <br /> _ <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder (0 Other g/ ca"r 4ew r <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> - - - - -- 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> f <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators I*In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: / tore r <br /> Bu <br /> 4ineslsep's Signature Phone Number c Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: ' W 62081 <br /> E X A L 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co <br />