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i Waste Tire S' .Ney & Inspection Repoi Inspection Report Number ■ <br /> cal Recycle State of California 11 - 1176411 <br /> CalRecycle (Rev. y(Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part-A-7 Survey_- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: L l ® Routine Q Re-inspection Q Referral O Observation <br /> Local c� ` If Referral,choose referral type(Fill one) <br /> Identifier: Y\ (b,/\V t CE'vVN,''Z.�J 0 CHP Q CalRecycle Q Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name L Inspected By Inspector <br /> Physical Address 5 I l C) <br /> g5 �z� h'trner L-il rv,1.�v i 1rW►Ib <br /> Inspection Date7 / c) / <br /> / <br /> Time In Time Out <br /> Business Rep Title / / , ®AM / @ AM <br /> �L()&X-. Jr�1�c ! v : C) d -o PM ` / o 0 PM- <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) :7 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> o 10 Active ® Passenger ® Generator Q Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned O OTR ® End-Use ® 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 /> 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 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 O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> 0 O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7J N <br /> O ® 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 /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations <br /> 1010 Other:§ <br /> z <br /> Comments <br /> V <br /> Inspection Form Included: <br /> Comments Included: <br /> Business Rep's Signatu Phone Number c r' Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X E X A L 112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Coy: © ■ <br />