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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1177509 <br /> CalRecycle R(Rev.y(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- 1 Lk 3 5 (� O S _ O Inspection Type(Fill one) <br /> Site Suffix: _l Q Routine le Re-inspection Q Referral Q Observation <br /> Local t / If Referral,choose referral type(Fill one) <br /> Identifier: �j(/�(\ J(�L(q u n 1.01/l Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l <br /> L Inspected By Inspector <br /> � M 0I' d \ ,A'1U+,,C I InS� rl //�� <br /> Physical Address 0 � C Sc O 17 <br /> T O <br /> 1320 t-f� D I r<-\ <br /> n �v L Inspection Date <br /> Time In Time Out <br /> Business Rep 1 Title <br /> � # AM i I 0 AM <br /> ('n d 71 r l c T'I.(1a 1��j�7 V 5 0 PM l � v Q PM <br /> 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 /> ®Active Q Passenger ® Generator Q Outdoor <br /> o Q Closed Q Altered <br /> Cid$ Latitude Q Hauler 40 Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude - Q Planned . OTR O End-Use Q Container <br /> Business Type(Fill all that apply) F I;f <br /> Q New Tire Dealer Q Auto Repair 0 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 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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 EXT) <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 Other:§ <br /> A _ <br /> Comments �V(OW-.) l 11 �J )S� )3. �� U N <br /> (� v1 Ou�i n wry fie{ <br /> IN�U 'c� i s a e_ <br /> Inspection Form Included: <br /> Comments Included: ) �2 ! A <br /> sin4Rep's gnature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: NJ E X A E 1 213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop : A ® 0 <br />