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Tire'*Vey & Inspection Re lo Inspection Report Number <br /> � Waste y p p _ ■ <br /> CalRecycle State of California1 <br /> i 11 - 1.1,7 6 ,47 9 <br /> CalRecycle lndR Revey(Ca 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 1 1 C _ ' Inspection Type(Fill one) <br /> Site Suffix: 1 "� J Q Routine Q Re-inspection Q Referral Q Observation <br /> Local I L If Referral,choose referral type(Fill one) <br /> Identifier: Yl�Q Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Al'�o <br /> Physical Address <br /> �1 0 ^ CA T�-ao Inspection Date <br /> Time In Time OutJ iii 1 <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM ® PM <br /> p 11 rC lJ� f til �. <br /> Operational Status The 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 /> ® Active 0 Passenger ® Generator ® Outdoor <br /> o Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use (a Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader ® 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 m m / 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 EXE 18459.2.1 <br /> a <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 /> 2 <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 1 Q 1 Other:§ <br /> Comments Rt)4\AA- Al U1S�'�- 11rC. ���(, i Pkb` ff yl V'n N)1w1c_—CanA N <br /> O A'i of �l'oris C)S (J-1CAs 0 Co<)Wn_ <br /> Inspection Form Included: <br /> Comments Included: <br /> �%hone�Nt� ' utoy 3usiness Rep's ignature Inspe s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct 0 Incorrect: zs� W �el I <br /> E X A P L 11213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C- <br /> : ® ■ <br />