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Waste Tire Su. dey & Inspection Report Inspection Report Number <br /> ornla <br /> CalRecycleCalRecycle <br /> CalRe gca of d Recovery/10)(Calcycle) Survey Form - Page 1 11 - 1230227 <br /> Dept.of Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I ' ` ` 1 9 _ O Inspection Type(Fill one) <br /> Site Suffix: y t `-� 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Y.\ �,�f,r;v�� Co vQ CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �"'� Inspected By Inspector <br /> Physical Address `` MA V <br /> �2 CSU W • A�►v.skmp�r�� 9CT. <br /> f�� Inspection Date 11 1 -2-(, / 1 <br /> 111 <br /> Time In Time Out <br /> t <br /> C� ql <br /> Business Rep Title � C> a � AM PM t OAM <br /> � J 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(W#.M101111 ' . (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 4V Active Q Passenger 40 Generator 0 Outdoor 35 <br /> O Q Closed Q Altered <br /> �PS Latitude Q Hauler 0 Indoor 1$ <br /> O Q Inactive 40 Truck <br /> Longitude Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fo •- wrw <br /> Q New Tire Deals. rwr+fir Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealw ii/r-l: Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station *low Q Agriculture Q Shredder Q Other <br /> Part B - Inspect— ,e 000116- "ae Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAUUW allllr 1 REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§4V;-- vamp -•^ruler Registration and Transport of Tires <br /> Q Q PRC§421WI° irsuwk .*►.Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42�-w «agmema.-0ecal in Vehicle <br /> Q Q 14 CCR§ —mp *omp—o.Entities Complying with Manifesting Requirements Date m <br /> Q Q 14 CCR§ ­,-0• -- +pram ID Number from CalRecycle <br /> Q Q 14 CCR b s+il > Somwttal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§ -00W.1 tiw omm of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§'0002 NNOM t System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q Q 14 CCR§ : o awry. System Requirements for Waste Tire End-Use Facilities W <br /> Q Q 14 CCR§ frown System Requirements for Tire Dealers or Waste Tire Generators .In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> s Gc Ces <br /> Inspection Form Included: `' <br /> Comments Included: W_ <br /> ep's Signature Phone Number Inspec is ignature Phone Number <br /> INSTRUCTIONS ON SACK Correct:* Incorrect: E X A L 1 213 62081 <br /> Nhite Copy:CalRecycle Yellow Copy:Operator Pink Co y:L <br />