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Waste Tire SAey & Inspection Reporplnspection Report Number <br /> CalRecycle State of California 11 - 1245066 <br /> CalRecycle (Rev.Recovery <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycte) <br /> Part A- Sury _ - _ — BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � ` - � I Inspection Type(Fill one) <br /> e6 ® <br /> Site Suffix: 0 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: __,,� '� Q CHP' Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name T / Inspected By Inspector <br /> Physical Addresh� fv( <br /> 57 <br /> 2 0. Co {v--a)l, bot <br /> 0 s3� Inspection Date O � V <br /> J / /` / s <br /> rc��7 CSI G <br /> Time In Time Out <br /> Business Rep Title O * AM <br /> � 1 : I O 0 PM � � �AMC) O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> a (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> �7 I 40 Active Q Passenger 40 Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive a 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 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 EXE <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 0 In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments &b V1 e—_ (3y\ <br /> Inspection Form Included: Q4pt <br /> �/Comments Included: w/� -- <br /> Bu Bess Rep's Signature Phone Number y's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS O BACK �Correct:la Incorrect: X EJXJA�M� PJL�Ej 1112 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />