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Waste Tire StA. fey & Inspection Re o�lnspection Report Number <br /> CalRecycle State of California - 1177633 <br /> CalRecycle 1$1(Rev.y(Cal Survey Form - Page 1 I1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> PartA-Survey BLUE OR BLACK_INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: L -7g Q ' Q Routine ® Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: Soh q V�h Vh Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name w Inspected By Inspector <br /> P�.c.e- 3 °l - � � A� A T <br /> Physical Address p"1/ \ 1 -T v <br /> 108c�- \ 22 --- <br /> �} �+ Inspection Date Q � / � / � 3 <br /> '����� L 5��� 9 Time In Time Out <br /> Business Rep TitleI C, //��, O AM O AM <br /> -{ lJ � PM � � 0 �PM <br /> Sinn Pte..w 0.� O w v1 e�(' <br /> operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole(F'I t) Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active 18 Passenger 40 Generator 41 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 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 /> • New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 40 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q 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 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 /> 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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE 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 /> 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 o <br /> Q Q Other:§ <br /> z <br /> Comments n_,.� �o �1.C�'V�.2 b'Y� �—S C�'� C�.V�c� '�►e �1(� .1 i Y`� <br /> � SP�c�• Ifs <br /> W a-S 1n o OZ <br /> Inspection Form Included: <br /> Zoq..qd8-3Zg`J. <br /> Comments Included;.0 - <br /> Bu ' Rep's Sig u Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Corr t: Incorrect: W g EXAMPLE 1 2 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />