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Waste Tire S,-.vey & Inspection Repot Inspection Report Number <br /> Cal Recycle State of California 11 - 1230325 <br /> CalRecycle (Rev.10/10) 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- 1 � � � ^ C r7 - © � Inspection Type(Fill one) <br /> Site Suffix: S J * Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local -..I ( If Referral,choose referral type(Fill one) <br /> Identifier: <br /> JQ C+l/1.1,n (Otk•nM 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Arne-( ,c rneA;utA PX-5?vnSe- <br /> Physical Address <br /> 1 �U / Inspection Date <br /> Time In Time Out <br /> Business Rep Q Titles \ / 0AM 0 AM <br /> Q 8 PM 3 0- 5 0 PM <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 0 Passenger ® Generator ® Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 5,6, 0 Hauler ® Indoor <br /> 0 0 Inactive Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other 5z Vel4crt,-0(2 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days N <br /> r <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> e In Compliance-No Violations o <br /> 0 1 0 1 Other:§ <br /> Comments LA31ASke- 05 c 'On " 111\�Y11s <br /> D V1U1�1 �U� cit afztAs o+ _�f)(-crn . <br /> Inspection Form Included: 0 L - <br /> Comments Included: 0 <br /> BusinesskRepSignature Phone Number nsp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: JEJXJAJ 1112131 <br /> 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy <br />