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■ 0 Waste Tire Suo vey & Inspection Repor , Inspection Report Number <br /> CalRecycle State of California TI - 1242250 <br /> CayclinglndRec very(v. 10) Survey Fora m (Page I <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 Type(Fill one) <br /> Site Suffix: li q 4g 5- l Q ( ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local C+ If Referral,choose referral type(Fill one) <br /> Identifier: ��� �CCnf/�1/�(�/\ �lC 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name �v / Inspected By Inspector <br /> Physical Address G l j4 � L <br /> Lq- <br /> acv n�. �,-,�,,j A-�e_ <br /> Inspection Date 8 / ) ';� ` <br /> / j L; <br /> ( -CA" CIS Q 3 7� me Z <br /> Time In Time Out <br /> Business Rep Title _ 0 AM 0 AM <br /> CLQ Q. PM PPM <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 /> ® Active 0 Passenger 0 Generator ® Outdoor <br /> 0 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 ® Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 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 /> Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> a <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 /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations <br /> 0 1 0 1 Other:§ <br /> Comments <br /> Inspection Form lncluded: <br /> Comments lncluded: itT-Y6 <br /> Business Rep's Signature Phone Number I p tor's gna re Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E I X A M E 11213 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop : ® 0 <br />