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Waste Tire dam, ,jey & InspecUon RepCOO Inspection Report Number <br /> CalRecycle State of California — <br /> Caycling le 187(Rev.y(Cal Survey Form o Page � I1 1242152 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ry ^ 1 o ® Inspection Type(Fill one) <br /> Site Suffix: `'� ` 1 * Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �GnA v�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> - Sam -_fir <br /> Business or Facility Name Inspected By Inspector <br /> Physical A ress <br /> Inspection Date Q <br /> Time In Time Out <br /> Business Rep Title 1 AM IB AM <br /> QPM V � ' � C) QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> 1 Tire Count (Whole/PTE) d (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> •Active Q Passenger 0 Generator 49 Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive 0 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 ! 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 O Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q 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 /> Q Notice Of Violation 0 Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators .In Compliance No Violations o <br /> Q 0 1Other:§ <br /> Comments <br /> %- c .,�_ <br /> inspection Form Included: 01 <br /> Comments Included: d �� <br /> Business Rep's Signature Phone Number Inspecthrs Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect: X7*7q1jEjXjAjMjPjLjEj 1112fl3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA ■ <br />