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Waste Tire S( ey & Inspection Reporw_spection Report Number <br /> Cal Recycle State of California I 1 - 1176654. <br /> CalRecycle t81(Rev. (Clal 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 Type(Fill one) <br /> Site Suffix: 1� 2? .Z 7 '4 3 0 (* Routine 0 Re-inspection O Referral O Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: w1 ZC t'_�, O CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> C-014 i '-fu rn i 0. MG.fGY-i <br /> Physical Address <br /> 5 arc �'1 Fc�-c0 f2cj, FJu <br /> Inspection Date l <br /> � f-oc.k�rn C� 4 ��is <br /> Time In Time Out <br /> Business Rep Title A AM _ ®AM <br /> 0 0 0 0 PM U 0 0 PM <br /> Irl Von Rvwl '- Slw� �✓w,w - - - -- <br /> —-- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> --7 <br /> T ® Active Q Passenger 0 Generator Q Outdoor <br /> - -_ - - 0 Closed <br /> GPS Latitude O Altered O Hauler ® Indoor <br /> O O Inactive ® Truck <br /> Longitude - O Planned 0 OTR O End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair O 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 Notice Of Violation 0 Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> f <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Other:§ <br /> Comments <br /> - <br /> �.n,l hd/cc/: - - — - --- - - <br /> Inspection Form Included: Q (/ <br /> e`Zeg) X62-CG23 <br /> Comments Included: - <br /> Business Rep's Signature7 Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK [CorrecA.!D�Incorrect: EXAM L E 1 2 3 <br /> j� �j� 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: <br />