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Waste Tire Sd%ey & Inspection Repori Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1245044 <br /> Ccyclin and R(Rev.y(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- Inspection Type(Fill one) <br /> Site Suffix: O 2 V I O Routine 0 Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sc 3-d v`r,' C5 VVN O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name` Inspected By Inspector <br /> Vko,Physica�Address `�c �� �e`5 c' _ 1 V M A -T TXJ,_ <br /> C1 Lb S., Ce- nuc S� <br /> S vc:.&'Vovn [��n-r Inspection Date 0 6 <br /> _1 ( Time In Time Out <br /> Business Rep Title 1 r7 *AMQ AM <br /> er S <br /> QPM � � � c- r♦ PMWOperational Status Tire Type Business Role Storage Type <br /> Tire Count hole/PTE <br /> ) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> `'` 0 Active ! Passenger • Generator • Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive 9 Truck <br /> Longitude - Q Planned O OTR O 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 pp,�`� <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 16 Other Wa5�c_ <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 Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date& / MO7 <br /> � Mks <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance-No Violations o <br /> O 1 O Otherr:§ <br /> Comments J OM� 1r���2C'�CS� �(�-1/�l'}u C l�� •��yL'CG�,\�_ � �'2- �, <br /> ` <br /> er <br /> Inspection Form Included: 0 e It <br /> Comments Included. <br /> Business Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: g E�XJA�MJPJLJEJ 11 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />