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Waste Tire Survey & Inspection Re orP Inspection Report Number <br /> CalRecycle State of California _ — <br /> Ccyclin and <br /> (Rev.Recovery <br /> Survey Form Page 1 I11245071 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BL <br /> Part A-SurveyACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- � Inspection Type(Fill one) <br /> Site Suffix: Q 1 r Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier `�( �) 16 qw, (b,, 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 1- 3 - 0 Ixy M� � <br /> Inspection Date � <br /> C�t or. C fi- 9sG <br /> Time In Time Out <br /> Business Rep Title j 5 * AM // O AAM <br /> I V 0 PM `-!' <br /> Operational Status Tire type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 ra� 0 Outdoor <br /> 0 <br /> ® Closed 0 Alt ed �' <br /> GPS Latitude 0 mo_ Gen 0 Hauler 0 Indoor <br /> 0 <br /> 0 Inactive Tr c — <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 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 Other Gry DL,rf I�LSt t <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 0 - 0 Notice Of Violation � Extension <br /> 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 <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) n <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 /> f <br /> Lu <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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 ,�Y�-�,� `�KLA �i 1'L.Q.�S'-�G!"1'Z'i'L� .y/Kx f✓YI ''�,�y� rot`- ,� <br /> �t)%� G�u�- old►- y� it I 1 ce tA:VV_0 rte - - �� �'rr>1�:-� � <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:18 Incorrect: 7X707q:f]jEjXjAjMjPjLjEj 1 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />