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I <br />Waste Tire Survey & Inspection Report <br />Gal Recycle State of California <br />Caycling let8l (Rev. y(Ca) Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />part A - Survey _ <br />Business Profile Inspection Details <br />TPID -1 O - 1 Inspection Type (Fill one) <br />Site Suffix: j J 0 Routine 0 Re -inspection 0 Referral 0 Observation <br />Local 1 If Referral, choose referral type (Fill one) <br />Identifier: -'�Q �l n 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name �\ �) <br />Inspected By Inspector <br />Physical Address ` 3 I , 0 1 CS (p U <br />a3�S y�l ovv� - <br />�� Inspection Date <br />-1, <br />\uL D 1 Time In Time Out <br />Business Rep Title ® AM 1 O Q AM <br />0 <br />txncA c- 0 P I 0 P <br />- Operational Status Tire Type Business Role Storage Type <br />Tire Count (Whole/PTE)r1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br />® Active ® Passenger ® Generator ® Outdoor <br />O 0 Closed 0 Altered <br />GPs Latitude 0 Hauler ®Indoor <br />O 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 <br />Inspection Report Number ■ <br />11-1226345 <br />BLUE OR BLACK INK PEN <br />Part B - Inspection of Waste Tire Dealer, Generator,.Hauler and End -Use Facility <br />V <br />A <br />I HAULING AND MANIFEST REQUIREMENTS <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 />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <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 <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 />0 <br />0 <br />Other: § <br />Comments i � w �c v -� l� I -r, L ��T to/�1 U,n/,INA (,T�`] <br />1- I <br />l Nyy i rJ�ct.si UJ1S NJ eyilPy l77 <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EX7) <br />0 Referred / CalRecycle Enforcement <br />Inspection Form Included: 0I pq-qy <br />Comments Included:, <br />fo <br />sin s ep's Signature Phone Number Inspe is Sigl <br />INSTRUCTIONS ON BACK I Correct:* Incorrect:) E X AMP L <br />■ White Copy: CalRecycle Yellow Copy: Operator Pink Copy: E <br />In Compliance - No Violations <br />uI -v �l 1' b <br />hone Number <br />62081 <br />■ <br />17 <br />N <br />a <br />0 <br />Lu <br />Lu <br />