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Waste Tire SL ey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1177541 <br /> CalRecycle t8l(Rev.y(Ca)l 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: 5 2 - ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ` ��.y-\ COA,) /\ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name t�` ` Inspected By Inspector <br /> �-o w �c'l C2 1 v Q vJ SQU� T�`\-_C, <br /> Physical Address`` - <br /> d ce `y v\cT�vS�t-T a� �u c�- C�•C. r 2 Z- <br /> Inspection Date I <br /> CA X153 3 7 <br /> Time In Time Out <br /> Business Rep Title O AM 20 00 AM <br /> U <br /> 4 yv_l PCJ�w Oma` Q U 1 h e_.0 Z O 9 PM / 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/� 3 <br /> 5 O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active 0 Passenger 40 Generator 0 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 /> 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 /> 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 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / Mic M13 <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 <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <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 Q In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments \ <br /> Acwe Y-\ <br /> Inspection Form Included: Q <br /> Comments Included: <br /> s Re 's Sig ature Phone N tuber Inspe tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK orrect:0 Incorrect: E X A M P L E 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />