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Waste Tire Sup Bey & Inspection Report inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1230218 <br /> CalRecycle cov.y(Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Surve _ _ ___. BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` O Inspection n Type(Fill one) <br /> Site Suffix: 0Routine QRe-inspection Q Referral Q <br /> Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �r eaocl�,v�v\ coV Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name�1 Inspected By Inspector <br /> Physical Address 1 M&T-T v <br /> t X01 �. C�ac� WG�r <br /> S ti CA qS Inspection Date I / 2 9 <br /> Time In Time Out <br /> Business Rep Title l Q 3 S PM 1 1 ' 3 S I All <br /> O PM <br /> �GS V t C' rc�o� ©W`ne� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I 0 Active 0 Passenger & Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <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 ­AHAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q 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 <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 /> 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 /> E <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 l � < <br /> T1n: Ca����n `}lam 'AY�_S��-1br1 �Qr1'� BVD. 4\,S " <br /> b t <br /> Inspection Form Included: Q 1,p �J Comments Included: "�' tr�,Business Rep's Signature Phone Number Inspecture Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct-:* Incorrect: X EXAM 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co y: © ■ <br />