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Waste Tire Sup vey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1177651 <br /> CalRecycle cover (CalRecycle) Survey <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- GCj _ O Inspection Type(Fill one) <br /> Site Suffix: J D ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalC If Referral,choose referral type(Fill one) <br /> Identifier: !0.h JC.>C Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> Vec; 20✓\ - <br /> Physical Address 1 C'_ <br /> 7 5 5 Cow�Co✓�Sx' 12 . <br /> Inspection Date 3 / -7 -7 / l 3 <br /> Ntav,�-�c� G•�' �tS336 J <br /> Time In Time Out <br /> Business Rep Title I O AM O AM <br /> Flte� S ®PM PM <br /> N aAPt- UJa%�^I k6o�mk Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (FII all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active 0 Passenger • Generator Q Outdoor <br /> o Q Closed Q Altered N 1" 1 <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 ® 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 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 <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 N <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 o <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 ®In Compliance-No Violations o <br /> Q Q1 Other:§ <br /> Comments ?-00` 1v. Wc. -Skt,` e-_ iY%Spe_t_&-i0j6 �nykf2 mylt T�zS C]Q�� <br /> RX <br /> N <br /> uc d(�- coAcervi <br /> Inspection Form Included: Q <br /> Comments Included: 0 / -,W-1713 <br /> _ usiness Rep's Signature Phone Number InspeE'tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: � � � EXAMPLE 1112 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />