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0 Waste Tire SL. f✓ey & Inspection Repor� Inspection Report Number <br /> CalRecycle s=ate of California 11 <br /> - .1230369 <br /> CalRecycle lel8fi(Rev.y[Cal Survey Form - Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A-Survey _ _ _. <br /> Business Profile Inspection Details <br /> TPID- Inspection <br /> t Inspection Type(Fill one) <br /> Site Suffix: 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local 0 Referral,choose referral type(Fill one) <br /> Identifier: 40.h �` �U� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name J <br /> Inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> e�h Time In 1 Time Out <br /> Business Rep Title Q O AM 1 ®AM <br /> DT � y PM � QPM <br /> Je Ve- rl,,,��`In. /45S+. <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' 0 Active 0 Passenger Al Generator 41 Outdoor 4 <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler 10 Indoor 27 <br /> 0 Q Inactive 49 Truck <br /> Longitude — Q Planned 0 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 0 OtherCom- <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 <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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 EX7) <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 1 Q 1 Other:§ <br /> Comments ,`� ` � �t sh�P�`l;o,r. Acme �,r. +S,�a►. c,�� <br /> Inspection Form Included: Q 20q_700+�26y <br /> Comments Included: <br /> Z// <br /> iness s Signature Phone Number Inspe tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X* L`�J EXAMPLE 1 2 3 62os1 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />