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Waste Tire SL wey & Inspection Repori inspection Report Number ■ <br /> State of California <br /> CalRecycle I 1 - 1196731 <br /> CalRecycle cover (Cal 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- inspection� � � � � _ 0 ` Inspection Type(Fill one) <br /> Site Suffix: ` * Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �oaq V`� V Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name y Inspected By Inspector <br /> Physical Addgdss <br /> MG AAoAn-\-e_ O\0.zVz) o`v 9— <br /> �k 95203 <br /> \\ 2 Inspection Date )1Q <br /> S"C oG��p Time In Time Out <br /> Business Rep Title 0AM S AM <br /> ` 1 1 ' 00 Q PM ( J QPM <br /> V�L�oC S• �O�S J22 �-OWv� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 2- (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger ® Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 <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 / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle F <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 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 /> g <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 /> 1010 Other:§ <br /> Comments��`� �v �t,�` ``Y�Q. \yG� �'e � _ Yee- <br /> Inspection Form Included: Q Aga A61-7 <br /> Comments Included. '"Cq) q �J <br /> ��q:7k 0q q& <br /> Business 's ature Phone Number Inspector's Signature Phone Number' <br /> �,{ 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X g E X A M P L E 1 12H3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />