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Waste Tire SCRey & Inspection Reporpinspection Report Number <br /> State of California <br /> CalRecycle 11 - 1245023 <br /> CalRecycle 161(Rev. (Cal 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- � � 1 ^ � 1 � � � � Inspection Type(Fill one) <br /> Site Suffix: y 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local /' If Referral,choose referral type(Fill one) <br /> Identifier: 7 J� �1� V.n Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By 1 Inspector , <br /> Physical Ad rd esA " \ 2, <br /> Gay-&.;v,c,-\ P,-4-r— <br /> Inspection Date <br /> C•' Time In V Time Out <br /> Business Rep Title O AM Z O AM <br /> CV3 evr\e Q ;�e O O 0 PM ' / dF PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> e Active * Passenger 0 Generator 40 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> o Q Inactive * Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 Q 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 /> 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 /> Q Q 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 EXE N <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <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 W <br /> V v I+���3 I o4uz-Ivlanitest aystem hequlrements Tor I Ire uealers or vvaste I Ire Generators IS In Compliance-No Violations o <br /> Q Q Other:§ <br /> Commentsm )&s 2cVzcA& aoy,-(2 oy\. k�-%s <br /> t� (5\e' �-' �S c�C Nfea-S 6� C©).cr C)A <br /> Inspection Form Included: Q <br /> Comments Included: ! 7 ro S� jS <br /> usine Signature Phone Number insp ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: jEjXjAMjPjLjEj 111213 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />