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,, Waste Tire vey & Inspection Repo. Inspection Report Number <br /> CalRecycle State of California I 1 - 1176586 <br /> CalRecycle (Rev.Recovery <br /> 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- l 4 r: Z C) I <br /> Site Suffix: Inspection Type(Fill one) <br /> IC 10 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: I,� �GcQ (,if0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> 001 ,,Fc_o 4- 10c J - t <br /> Physical Address /]___4VA4 /3Z�t�• <br /> �b -ZG j <br /> Key inoWS �T7l7 <br /> Inspection Date <br /> L06 , GtA G� zed <br /> Time In Time Out <br /> Business Rep Title ® AM AM <br /> � PM � l � '� � PM <br /> M�C.L1Qt!� 1'luwttc� �� sv zoY <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) a (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active * Passenger IS Generator 0 Outdoor <br /> O <br /> GFS Latitude 0 Closed 0 Altered 0 Hauler 0 Indoor <br /> o 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 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 /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> i <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 0 Other: <br /> Comments 44 ct SkA !Si CA <br /> — 11CA4 i-na. G<<EC taQkef <br /> Inspection Form Included: 0 <br /> Comments Included: *II <br /> Business ep's Signature Phone Numberspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct Incorrect: E X A L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co y: A <br />