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� Waste Tire SL. Bey & Inspection Repor. <br /> Inspection Report Number <br /> CalRecycle State of California I 1 - 1242423 <br /> CalRecycle (Rev.10/10lRecovery <br /> Survey Form - 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- n !, 2 _ O 1 Inspection Type(Fill one) <br /> Site Suffix: ! `� J 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �p�G Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _—1 Inspected By Inspector <br /> Oa.�Ac-_ arc <br /> Physical Address <br /> 131$ �vQc � Cir. <br /> oAecC11- 'f <br /> Inspection Date 0 -7 <br /> l� 95336 / <br /> Time In Time Out <br /> Business Rep Title O O AM C O AM <br /> N1CAV .e �n 1 0 PM J • PM <br /> C 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 Active Q Passenger 4D Generator Q Outdoor <br /> Q Closed Q Altered N/A <br /> GPS Latitude Q Hauler Q Indoor <br /> C Q Inactive 0 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 0 Trucking Fleet Q Government Q Retreader 0 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 <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 /> 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 EXE <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 /> 010 Other:§ <br /> Comments <br /> ba Ypar <br /> Inspection Form Included: Q <br /> Comments Included: • l ! 2� �� ���!Nu5b <br /> L <br /> Business Rep's Signature Phone Number Inspector's Signature Phoneer <br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect: jEjXjAjM� PjLjEj i 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />