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13142040196 <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1186130 <br /> Dept.of Resources Recycling and ReCalRecye 181co ery(CalRecycle) Survey Form e Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- i / / L/ � Inspection Type(Fill one) <br /> O � 6 <br /> Site Suffix: b 11II ®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 <br /> Inspected By Inspector <br /> L-1-i3d oddress b O , I LS <br /> Stree�35_1 � � �4 <br /> m—Zkv_\'.-/� GSI 9533 6 Inspection Date <br /> City r State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM t/ /`+ G{ 0 PM <br /> � � 4a <br /> —� Operational Status -Tire Type'-. Business Role Siorage Type <br /> Tire Count(Whole/PTE) + (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 ' V 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> D 0Closed 0 Alte�ed�: <br /> GPS Latitude m . TTI .?e 0 Hauler `0 Indoor <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 ® 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 <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 0 0 Notice Of Violation 0 Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 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 /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> w <br /> 0 if 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance-No Violations o <br /> 0 0 Other:§ I _ <br /> i <br /> Comments <br /> \J0 1S n s ror. ' Al Wr L a i / N <br /> 3 ,,.-�,s �fi�f o .v I��l ►;o � oma. ��- � <br /> Inspection Form Included: 0q )p <br /> Comments Included:,Oyu <br /> siness Rep's Signature Phone Number Inspectors Signature Phone Number. <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:I. Incorrect: X E X A M P L E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />