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Waste Tire ley & Inspection Repor Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1226277 <br /> CalRecyclel8t(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recyclingyclingand Recovery(CalRecycle) <br /> Part A- Survey _ _ BLUE OR BLACK INK PE_N <br /> Business Profile Inspection Details <br /> TPID- 3 7 Inspection Type(Fill one) <br /> O y O <br /> Site Suffix: J 3 Z `I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> a!Y1 c. ki � Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other � <br /> _ <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address / /2,T/ jV <br /> � � Inspection Date Z Z J <br /> "lG�,vv+t cc-c CA � 533} <br /> Time In Time Out <br /> Business Rep Title O AM //�� O AM <br /> '1i Iii �C+Ck S rid !J'I!t l' 0 2 3 0 ® PM V 0 PM <br /> y'`fi n1L C(�o nC�l -�j1— r� r 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 /> ® Active ® Passenger ® Generator ® Outdoor <br /> GPS Latitude Q Closed Q Altered Q-Hauler -Q-indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q 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 ® Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> i <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility rENFORCEMENT 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CalRecycle f N <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for or N <br /> a <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 <br /> Q Q Other:§ <br /> --- <br /> Comments <br /> e is i C e '(7 <br /> deft. caAAICA 4�0 (C t <br /> way ne�+c-cl : -- <br /> Inspection Form Included: Q <br /> Comments Included: ® ` uco2 23 <br /> Business Rep's Signature Phon umber nspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: M E X A P L 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co : <br />