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Waste Tire SAey & Inspection ReporOnspection Report Number ■ <br /> Cal hcyde State of California I 2 - 1230374 <br /> CalRecycle ifRecov.Recovery <br /> S1 f1C"vFoy For6'A'® © P�1(rj e I <br /> Dept.of Resources Recycling and Recovery(CalRecycle) hl�Il h�yj' Form®C7 Page� <br /> Part A-Survey FLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1A � � � � _ ,� 1 Inspection Type(Fill one) <br /> Site Suffix: 1 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �0 Qq V r �V Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Y <br /> Inspected By Inspector <br /> Physical Address 3c) - 1 1 <br /> CInspection Date D 9 <br /> Ti <br /> I <br /> Time In Time Out <br /> Business Rep Title C 0 AM �t� (q 10 AM <br /> 5 I C) ' � J 0 P V -1 0 P <br /> �1A�119 i5 MOL%A 7O Gcvi l�C. <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) I U (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' _1 4W Active 0 Passenger f Generator Q Outdoor <br /> O Q Closed b Altered <br /> ��� Latitude Q Hauler ` Indoor <br /> O 0 Inactive 4P Truck <br /> Longitude - Q Planned OTR 0 End-Use Q Container <br /> Business Type(Fill all that apply) f <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body 0 Car Dealer Q Collection Q Crumb Rubber <br /> 0 Service Station Q Hauler Q Agriculture 0 Shredder 0 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 � Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> O 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 EX ) N <br /> a <br /> 0 O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years � <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 0 0 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 /> 0 1 0 1 Other:§ <br /> Comments <br /> o <br /> Inspection Form�nc <br /> ncluded: 0 2-09-A <br /> Comments Euded: * • <br /> Business Rep's Signature Phone Number Inspe tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: 7X7441 EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />