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Waste Tire Sikey & Inspectio i l- a on Inspection Report Number <br /> Cal Recycle State of California I 1 - 1177867 <br /> CalRecycle (Rev.Recovery <br /> Survey Fore © Page <br /> Dept.of Resources Recycling and Recovery(CalRecycle) V � V tl �i <br /> Part A- Survey - --BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- b { e 'r� l Inspection Type(Fill one) <br /> Site Suffix: J .) v / ® Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: J all Dal 141, l Uu(C+� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> (vim� l o Inspected By ) Inspector <br /> Physical A �S CL�� (J��(l S((��P1_ - <br /> Inspection Date <br /> CJ �� Time In Time Out <br /> Business Rep Title f) ' O AM O AM <br /> a 0 6 ® PM Q, � v ® PM <br /> - - -- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) �y (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 /> Cads Latitude O -0 Closed Q Altere I AMA NIA <br /> o Q Inactive Q Truck Q Hauler Q Indoor <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 Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other . `� s j,, �0, <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 /> 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 EX7) 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 /> Lu <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 /> CommentsWtiS�P }ire 10 't n IA rA O�41" � Gf—A v 7W L) _ `mss (1I�A��: <br /> t �J <br /> Cbner.cn1i. _ <br /> Inspection Form�nc <br /> ncluded: Q <br /> Y <br /> Comments luded: Q <br /> Business Rep's Signature Phone Number lnspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: k�qE X A P E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink <br />