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Waste Tire Survey & Inspection Repon Inspection Report Number <br /> CalRecycle State of CaliforniaR I 1 - 1230313 <br /> CalRecycle 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- r $ 0. S 1 - 0 Inspection Type(Fill one) <br /> Site Suffix: 6 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalA n (0�ry}�n If Referral,choose referral type(Fill one) <br /> Identifier. 'J Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 39 <br /> Physical Address ~ C$(V`FT <br /> as 3'1� <br /> Inspection Date <br /> SUL�'LJI f r� Time In Time Out 1 <br /> Business Rep Title O AM 1 ` O AM <br /> K t Mm Love 1`u LQ. oi+l'� � f, � � 0 PM � ` ••� O PM <br /> -- Operational Status Tire Type Business Role Storage Type <br /> 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> * Active Q Passenger ® Generator Q_Outdoor <br /> O Q Closed Q Altered !� <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 40Truck <br /> Longitude - Q Planned Q OTR 0 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 IQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 EJCT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators e In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> Comments 12041irv-1 �6 i� 1 f1 N <br /> V <br /> o- �f�.u�s bT C f)cern- <br /> Inspection FormIncluded: Q *.►�JL 9 $ - �� <br /> Comments Included: ® /v�/ 09 <br /> Business Rep's Signature P orA(umifer Inspec 's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: � � � E X A M P E 1 213 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:&/ <br />