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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle CalRecycle <br /> (a 11 - 1255964 <br /> CalRecycledR(Rev.yH0) �::�ppromsey For(3it�l — Page `�� <br /> Dept of Resources Recycling and Recovery(CalRecycle) Survey�LJ3 II Y�i ��Il ��-8 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �, Inspection Type(Fill one) <br /> Site Suffix: { t l> ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: 56L r L )4'Cgi vi o cc Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> A V V- ✓Sa_�'5 u-0-L?� V ' - � d � <br /> Physical Address - C 'Y <br /> Inspection Date <br /> Time In 1 Time Out <br /> Business Rep Title /,j �j Q AM ® AM U 0 (� Q PM I ' `I Q PM <br /> �/l(N eLoS �i <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 7 ' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger ® Generator o Outdoor <br /> O Q Closed Q Altered <br /> GpS Latitude Q Hauler Indoor <br /> 0 Q Inactive 49Truck <br /> Longitude - Q Planned Q OTR Q End-Use Container I <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 I HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <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 EXTJ N <br /> a <br /> Q Qb 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 In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> Comments Vc-�w_Q waeA Lf, 766- 1Le gid dCycu 0b, Aw d ah <br /> c �C1 <br /> Inspection Form�nc <br /> ncluded: O 1-v <br /> Lv ��^t <br /> Comments luded:* , <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: 7X 4 NJ IEIXIAIMIPILIEI 11 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />