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Waste Tire S-. ✓ey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 11 - 1177753 <br /> CalRecycle R(Rev.y(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- � � � Inspection Type(Fill one) <br /> Site Suffix: o Q Routine ® Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SQn To 0.q V\r Co V VL�y Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name L Inspected By Inspector <br /> D v b C'.>s�e,v„\ 9 - 1 0 1 Al TU <br /> Physical Address <br /> 9SInspection Date 5 V g / 1 3 <br /> ZoS <br /> Time In Time Out <br /> Business(Rep `` Title// O AM O AM <br /> '4V"-VCc.CJ� V w V1 e,(- I ® PM Z z ® 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 /> C <br /> J ® Active 0 Passenger ® Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned i OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 I HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / 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 EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years N <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 u, <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 <br /> `�ev�oySyiGtcAt0vxS VcL_ue 1oct�n C©rcec�E'C� <br /> �o V�ola�li ov�s o c o�cz<S 0 - Cool ce ryl <br /> Inspection Form IncludedQ <br /> Comments Included' *__ Phone <br /> nCe�r Number <br /> mbUe4r�-twIpIns "+C 'r�S--siBusln ep s signature /nature <br /> f/ 2dqL CwPho <br /> ne-�Number <br /> INSTRUCTIONS ON BACK Correct:10 Incorrect: g C X A M P L E 1 273 <br /> 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />