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® OM Waste Tire S6, vey & Inspection ep®n Inspection Report Number <br /> CalRecycle State of California I 1 - 1196673 <br /> CalRecycle R(Rev.y ll 0)(CalRecycle) Survey <br /> S rvey Form o Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) M <br /> Part A-SurveV BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 0 Inspection Type(Fill one) <br /> Site Suffix: © 1 -7L L— O 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: J O0.�y'`�. � 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> SS 5 )v• l�o.`�� 5k-C <br /> Inspection Date ' / L , ' 3 <br /> mo,IV\krec� C,A� X153 <br /> Time In Time Out <br /> Business Rep Title 0 AM t A j� O AM <br /> * PM `L V 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) v� 2 (Fill one only) (FII all that apply) (Fill all that apply) (Fill all that apply) <br /> i 7 Active Passenger 4j Generator Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 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 ` 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 <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 N <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle 3 <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> v <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 /> Lu <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 1 0 Other:§ ` <br /> Comments <br /> Inspection Form Included: 0Oa �2a <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> �-, <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: _4-1�JE X A M P L E 1 2 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />