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■ Waste Tire SL. Bey & Inspection ReporOnspection Report Number <br /> CalRecycle State of California I 1 — 1242230 <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- inspection� 1 � � � - Q ` Inspection Type(Fill one) <br /> Site Suffix: &Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5CLV\ V�� ��� O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name y Inspected By Inspector <br /> Physical Address <br /> -767S �,,, tiItn Sk , - — <br /> Inspection Date 07 / 2- <br /> Time <br /> Time In Time Out 1 <br /> Business Rep Title < O AM 1 Q AM <br /> o� �Vte.ge.co5 (.-exp•�C'. <br /> 2 S IPM I S 4 P <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 /> Q Active O Passegger Q Generator Q Outdoor <br /> Latitude LA- <br /> O 0 Closed Q Alt e <br /> GPS Q Hauler Q Indo r' <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 ��\1 ek4�V �•�1 Qe` <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Extension <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> QO 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) n <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> w <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> Q 1 Q Other:§ <br /> Comments <br /> tW.s <br /> �2c�r2S` t r 1�ac:.\��v �����_�et� c�W�e�s1n,`P��o.c:�����i•�� �_ys;�� <br /> Inspection Form included; Q � <br /> Comments Included: O <br /> Business Reps Signature Phone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect: X �t EXAMPLE 12 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />