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Waste Tire Sgey & Inspection Report <br />State of California <br />CalRecycle 10/10) <br />Dept. of Resources Recycngcand R cR <br />l very (CalRecycle) Survey Form - Page 1 <br />Part A - Siirvpv <br />Inspection Report Number <br />I1 - 1242198 <br />BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPID - <br />Site Suffix: G C <br />Inspection Type (Fill one) <br />® Routine 0 Re -inspection 0 Referral 0 Observation <br />Referral, choose referral type (Fill one) <br />0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br />LocalIf <br />Identifier: <br />Business or Facility Name r <br />Inspected By Inspector <br />PhysicafAddress <br />�7 ' �./ A h <br />61-1 C�✓nv� sz�� <br />1112 <br />Inspection Date 78 8 <br />Time In Time Out <br />Business Rep Title <br />f✓ <br />Alc�ym_ <br />1 0 AM Q AM <br />l Z —1 3 0 PM % / � ® PM <br />Operational Status <br />(Fill one only) <br />® Active <br />0 Closed <br />0 Inactive <br />0 Planned <br />Tire Type <br />(Fill all that apply) <br />9 Passenger <br />0 Altered <br />0 Truck <br />0 OTR <br />Business Role <br />(Fill all that apply) <br />® Generator <br />0 Hauler <br />J$ End -Use <br />Storage Type <br />(Fill all that apply) <br />4& Outdoor <br />0 Indoor <br />0 Container <br />Tire Count (Whole/PTE) a Q <br />GPS Latitude <br />0 <br />Longitude - <br />Business Type (Fill all that apply) <br />® 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 I& Other <br />Part <br />B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />0 Notice Of Violation 0 Extension <br />0 <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date <br />0 <br />0 <br />0 <br />0 <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />(Required for NOV or EXTJ <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 Referred / CalRecycle Enforcement <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />In Compliance - No Violations <br />0 <br />0 <br />Other: § <br />Comments <br />Inspection Form Included: 0 <br />Comments Included: ® <br />c� <br />Business Rep's Signature Phone Number Ir0P&or06g5dture Phone Number <br />INSTRUCTIONS ON BACK <br />I Correct: <br />Incorrect: g <br />EJX�Aj <br />1112 <br />31 <br />62081 <br />White Copy: CalRecycle <br />Yellow Copy: Operator <br />Pink Copy: <br />