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0 Waste Tire S( fey & Inspection Repor' Inspection Report Number ■ <br /> CalRecycle State of California I 1 1177570 <br /> CalRecycle ed Recovery <br /> 10/10) <br /> y(Cal 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: ' Z 5 O 9 • Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5CIVI, Oomd V�h V�"r�/ 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business onfacility Name Inspected By Inspector <br /> �,,,, <br /> Physical Address ���v S <br /> M Inspection Date <br /> Ma`���C 0. L �5 ��� Time In Time Out <br /> Business Rep Title AM AM <br /> I� <br /> C7 ' ti D O PM 0 PM <br /> eY\�e- ��.1�� Sec c���� <br /> - — --- - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) ^ O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' L 0 Active Passenger Generator 0 Outdoor <br /> GPS Latitude 00 Closed 0 Altered <br /> Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 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 /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> f <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> 0 0 ,Other:§ <br /> Comments �zOy�iv� I,Jo-Sk2 i @ vtS p eC�tLC)✓� \\ 1 <br /> ClLCS toe v\-__C�n S Ot ' <br /> Ck_V\A_ kk-�,e 1\0 w�� hA as vL rs <br /> Cc)V\,cr c,n <br /> Inspection Form Included: 0 �0�� Z^c —Lt6 3�g <br /> Comments Included: - " l <br /> _ Bus6�2nature Phone Number Inspec or's Signature Phone Number <br /> k Q EXAMPLE 1 2 3 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ® ■ <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />