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Waste Tire SAey & Inspection Reporpinspection Report Number <br /> CalRecycle State of California I 1 - 1255978 <br /> CalRecycle (Rev.Recovery <br /> 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 Type(Fill one) <br /> Site Suffix: 1 6 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: JC)i;/;V y\ C��� J Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` ' Inspected By Inspector <br /> '.S <br /> vo_ 5 Q" a_V' / l'i C-eS �' ��ne e�S �Kc a - d � 1 V <br /> Physical Address / —` <br /> Inspection Date 0 1 / 0 "A / 16 <br /> Lo� <br /> 017 qszlo lJ <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> us <br /> / ¢.` 40� � I � PM � I � �PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) Z <br /> Z (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger Generator Outdoor <br /> O 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 0 Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer 0 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 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q 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 <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 EXT) 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 /> 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 <br /> ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Commentsy_ \��Q �j0.s A�__ <br /> TNP _ ,�O <br /> 116Tr�; <br /> 0 <br /> Inspection Form Included: QJ. <br /> A, " <br /> Comments Included: 0 7 <br /> Business Reps Ignature Phone Number Inspector's Signature Phone Number <br /> � 62081 <br /> INSTRUCTIONS ON BACK FCorrect,0 Incorrect: LEIXIAIMIPILIE1 1112131 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />