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Waste Tare S.-vey & hspection Repor, Inspection Report Number <br /> CalRecycle State of California �a I 1 - 1245128 <br /> CalRecycle (Rev.y(Cal `fl fl�'1vey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) v-'U-d �s <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � /f 5" y � _ � I Inspection Type(Fill one) <br /> Site Suffix: f C..� • Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 411 I Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> _Do(_)c4a {gyral, °1 I U I �' <br /> Physical Address - �kioDV f _ f _ <br /> Inspection Date / Z_ 3 `j <br /> G �S24C <br /> Time In Time Out <br /> Business Rep Title O AM ] O AM <br /> f�01D C) 175O e PM 1 4W PM <br /> Operational Status Tire Type Business Role Storage Type <br /> ) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count �h)le/PTE) <br /> 0 Active O Passenger 0 Generator • Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> I <br /> Business Type(Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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§429.56-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / <br /> m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle q <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments , <br /> n <br /> Inspection Form Included: Q Z'9 2 <br /> Comments Included: <br /> Bus ness Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />