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Waste Tire Si f ey & Inspection Repo Inspection Report Number <br /> CalRecycle State of California 11 - 1226556 <br /> Ccyclin and"R' cover (Cal Survey Form - Page 1 <br /> le <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 I Inspection Type(Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name �yyt Inspected By Inspector <br /> PhysicarAddr se s � ��/- � � � _'� - Q <br /> L� / / 30f7-7-Cov <br /> Inspection Date <br /> CA <br /> Time In Time Out <br /> Business Rep Title 0 AM O AM <br /> (n / . O O ® PM S � * PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 3 ) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> Latitude O0 Closed 0 Altered Hauler <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned ® OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 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 /> O 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 /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> f <br /> O 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations <br /> Other:§ <br /> Comments <br /> ►1UIft 90CG 6 L4^-, AJ j 92 2&1C.lri�l AIAA'Z&Ca..z�— - <br /> Inspection Form Included: 0 (� <br /> C2 <br /> x �)'-V� <br /> Comments Included: � Business Rep's Signature Phone Number nspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A M PJL 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Coy <br />