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Oa Waste Tire Su. ✓ey & Inspection Reporit Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1230219 <br /> CalRecycle 187(Rev.y(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- inspection� � O � 5 _ O � Inspection Type(Fill one) <br /> Site Suffix: Routine 0 Re-inspection Referral Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: V`VN l.E7yIN Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By t Inspector <br /> S0.wS� �r 2S Gr�,_ 15�7� S -3 9 - I d 1 AIA 1 1 <br /> Physical Address <br /> CVN <br /> Inspection Date � � / 2 <br /> Time In Time Out 1 <br /> Business Rep Title 1 16 AM 1 10 AM <br /> L ® S 0 PM t 0 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> O 0 Closed QAlteredtA NIA AA <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 /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader O 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 /> �Notice Of Violation � Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0­0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 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 EX7] N <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 O Referred/CalRecycle Enforcement <br /> w <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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 C&Lv%e mys it C (No_� D`k "Yh$ � IIO LOI r( -�A q.S <br /> !� 1•) 'S T,�es o.anJ� 9�40Q_S -15 nt-, <br /> 1 o�Ps a k- 5 1c�ca io►'�- 1�1 ems_ <br /> 1'vzes <br /> Inspection Form Included: O <br /> Comments Included: O <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: :X*V]jEjXjAjMjPjLjEj1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA <br />