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Waste Tire Su, ✓ey & Inspection Report <br /> Inspection Report Number <br /> Cal Recycle State of California — <br /> Ccyclin a 18i cover (cal Survey Form - Page 1 I11230408 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I r ry / _ Q I Inspection Type(Fill one) <br /> Site Suffix: I* Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Soh �a a���� CO��r�/ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address - 1 MA V <br /> 10\oQ V.-Q�Se�et� V� <br /> Inspection Date 0 q <br /> �Sco�vY1 CA q s 3Z0 1 <br /> Time In Time <br /> Out <br /> Business Rep Title ,AM 'AM <br /> l O O PM ' l l I 0 PM <br /> olr �?-ow+c /�'I,ux+��rarcZ Nl,a� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> 49 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> "� 40 Active • Passenger 0 Generator 0 Outdoor il <br /> O Q Closed Q Altered <br /> GPS Latitude � Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q End-Use r, Container <br /> Q Planned Q OTR y <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I 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 EXTJ 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 m <br /> Q 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 <br /> )Aae_ ae Al"%its t ..AUK <br /> bnv oa ok"-yllS pC cLS O�- Curd � <br /> Inspection Form Included: Q _ <br /> Comments Included: ® �/'�i <br /> 2df — Sr3 S"'—/Y y //'6u* 20 Y—y6&_, 0 <br /> Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA ® 0 <br />