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Waste Tire Su. #jey & Inspection Report Inspection Report N;tuber <br /> CalRecycle State of California 11 - 1230250 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form — Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- n Type(Fill one <br /> Site Suffix: 6 z 'S2 DRoutine QRe-inspection Q Referral Q <br /> Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S0_y_-' Toni-to;r -651-_3 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B Inspector <br /> P Y P <br /> Physical Address <br /> \ `- ` I Inspection Date <br /> S`0Gw�`^ �X 95202 Time In Time Out <br /> Business Rep Title CZ S O AM O AM <br /> ✓ QPM � � � QPM <br /> 3, bha4_S01/" dW V.-2-( <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Who /PT (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f b 0 Active *Passenger &Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 18 Indoor <br /> O Q Inactive • Truck <br /> Longitude - Q Planned OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 0 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 /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> a <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 /> Uj <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 /> 010 Other:§ <br /> Comments e_ l>s Q.S}e_ c,,, 15 Aak _ <br /> 19�6`10�, O CeCAJ5 a�- KCeC V� <br /> Inspection Form Included: Q <br /> Comments Included: <br /> usiness Rep's Signature Phone Number Inspect is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X � q1jEjXjAjMjPjLjEj1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />