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0 Waste Tire Sup Bey & Inspection Report inspection Report Number <br /> CalRecycle State of California I 1 - 1230174 <br /> CalRecycle (Rev.Recovery <br /> 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- I �� Inspection Type(Fill one) <br /> b <br /> Site Suffix: I 6 � � _ � , * Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� r� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name PP Inspected By Inspector l <br /> PhysicalAddress <br /> ddres SI C«� -+ I 6... S <br /> �0�� S• �wy 9°\ !PcoA4r <br /> TOS I C,4, Inspection Date � j'\ / <br /> 952o7 <br /> Time In Time Out <br /> Business Rep Title0 AM 0 AM <br /> ' 0 PM 2 : ,2 S 4&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 Q Passenger • Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive 4&Truck <br /> Longitude — Q Planned Q OTR Q End-Use Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 19 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 9-19-e <br /> — <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 <br /> m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE04 <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 ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments ` ®y\e. ®N\ 1� S <br /> n. 60^r-ern <br /> Inspection Form Included: 0 —O <br /> Comments Included: �! �. 1k~3W <br /> Business Rep's Signature Phone mb r Inspector's Signature Phone Number <br /> �( <br /> INSTRUCTIONS ON BACK Correct:IS Incorrect: � � NJ �JEJXJAJM P L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />