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Waste Tire Survey & Inspection Report inspection Report Number � <br /> cal Recycle State of California 11 - 1177732 <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- � � � 2� 1, 'So � 1 Inspection Type(Fill one) <br /> Site Suffix: -I * Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �0� V1�n UY` Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 'T�-00'0Se_v\ lam`c��e�o Se "'�`�a�`/ - O T T U <br /> Physical Address <br /> 1565 w� �lacoskti.,,�c Dr. - - - - - <br /> Inspection Date S l / 1 3 <br /> CA_Cy CA 376 <br /> Time In Time Out <br /> Business Rep Title AM C 0 AM <br /> 1 O QPM I 2- J QPM <br /> Nla�l� Ct �Sl�e�� �eh Ma ,zf <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 /> • Active Q Passenger ® Generator Q Outdo/or A <br /> O Q Closed Q Altered �` <br /> GPS Latitude <br /> O Q Inactive Q Truck Q Hauler Q Indoor <br /> Longitude - Q Planned OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) iC <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 <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 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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle ut <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <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 /> Lu <br /> Lu <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities —__ <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:§ z <br /> 1 i` <br /> Comments 1� U��1nC 1 ►.1 Gs�L 1 lrC. l �bY\ _��1L�p nyt kk%Zs j'4�e N <br /> _ [-OaCL.e �,ltow:rte t�O's YL-0 <br /> C MS_ cst� Ca nceT-tn, <br /> Inspection Form Included: Q ing. )A PX-'\k -gZ Q 4 <br /> ` Zc�q-�6$- v / <br /> Comments Included: <br /> Busin s ep s ignat re hone um er Inspe or's Signature'— Phone Number <br /> -- - 111 62081 <br /> INSTRUCTIONS ON BACK Correct:l, Incorrect: V j JP[LJEJ 1112131 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />