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0 Waste Tire SL iey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1230238 <br /> CalRecycle 1 ry(Rev.y(Ca(Call Survey Forme- Page 1 <br /> Dept.of Resources Recycling and RecoveRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- i � O 6 -26 <br /> � /� � � O I Inspection Type(Fill one) <br /> Site Suffix: 1 b ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �+ If Referral,choose referral type(Fill one) <br /> Identifier: C%_V'\ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> � 5 l cLA <br /> Physical Address <br /> 3O7 b vV\k 6Y, ` <br /> Inspection Date l 2 / d <br /> Time In Time Out <br /> Business Re ii� 2 0 AM 1 AM <br /> Rep Q / D Q PM ` PM <br /> �vcln.s 8 �'Gn - <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 /> Q Active Q Passenger Q Gene ator Q Outdoor <br /> O ® Closed Q AI r �4 <br /> GPS Latitude QNa. r Q nl ddor <br /> O Q Inactive Q 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 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 `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 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <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 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 /> 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 <br /> ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> 227-<0L <br /> �a - <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Bu e s n Pho a Number Inspect s Signature Phone Number <br /> INSTRUCTIONS ON BA C rect. Incorrect: EXAMPLE 1112 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />