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Waste Tire Su. ,iey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 11 — ! 2 4 2 3 9 5 <br /> CalRecycle (Rev.Recovery <br /> Surrey Form m 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- ' � � c , O ^ Inspection Type(Fill one) <br /> Site Suffix: "� ! S Q Routine ® Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � v�Y� C .y��` Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address Q <br /> 1550 1�. C�f.��s`�`n Qct•• <br /> Inspection Date O 3 / C) <br /> Time In Time Out <br /> Business Rep Title i O AM 2 ^� O AM <br /> 1 1C) f0� PM � J V o PM <br /> C���aG.s Gam. �. <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 /> 0 Active Q Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler <br /> O Q Inactive 0 Truck Q Indoor <br /> Longitude — Q Planned * 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 1[ tNC' 4k'CK\ cc'' s <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 Q - -- Q Notice Of Violation Q Extension <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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 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 /> Uj <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 1 Q 1 Other:§ <br /> Comments ` <br /> .v.S .pQ c-s <br /> �ce.�.c�.sS v:o���t �► .V•c�s be�c\ cocccc � �o nv` o c akms Can tg tV% <br /> rl__k_ <br /> vAckw-Atr'� r 2. o <br /> \ -t <br /> ev <br /> Inspection Form Included: Q <br /> G� <br /> Comments Included: Q z�r-� -o Z 2-cl-y68-3Z8y <br /> - <br /> Business Rep's Si Phone Number I�nspeAr's�ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct:4 Incorrect: jEjXjAjMjP � LjEj 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />