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Waste Tire Su, ojey & Inspection Report inspection Report Number <br /> CalRecycle State of California I 1 - 1196253 <br /> CalRecycle 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� Q � � � - Q 1 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: a V ^ Cov,'AJ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 rr ( Inspected By Inspector <br /> kv�t C1.'e.SKCy\ <br /> Physica � ss <br /> \ Inspection Date <br /> S TbG��CUY� C� �52�5 <br /> Time In Time Out <br /> Business Rep Title Al <br /> AM <br /> I V O 0 PM 1 ' 0 PM <br /> hY Sc. :c� cer�nnc�r <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) n (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' L 0 Active Q Passenger 0 Generator 0 Outdoor <br /> Q Closed Q Altered <br /> ��� Latitude Q Hauler Indoor <br /> O Q Inactive Truck <br /> Longitude - Q Planned OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 40 Other V`SNVN611�_Y\ Ce3r\'C� <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 /> 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 EX) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments `S <br /> �rZ•r• J,�aS�d. '�:ct�_ 1��2..c�c3o� �Z rah. �a--F- <br /> Inspection Form Included: 0V <br /> _q <br /> Comments Included: * <br /> Business Rep's Signature 'Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � q 11 E�XIAIMI P I Ll El 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />