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0 Waste Tire S+9vey & Inspection Repor, Inspection Report Number <br /> CalRecycle Stere of CaliforniaCalRecye I 1 - 1210433 <br /> Dept.of Resources Recycling andgRecovery(CelRecycle) Survey Form - Page 1 <br /> )art A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Sufflx: I f � D S I � - 0 l Q Routine Q Re-inspection 0 Referral Q Observation <br /> Local I �.... t 1 If Referral,choose referral type(Fill one) <br /> Identifier. S(AA J LO nT Q CHP 0 CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I Inspected By Inspector <br /> � i _ I f'� f l ltysical Address �Ec �rO ! <br /> C <br /> Street I i <br /> � , / Lois] <br /> ' Li <br /> Inspection Date11 t-3J <br /> �c�nc�_C�-rnP CA G SZ'SJ� <br /> City State ZIP Code rime In Time Out <br /> Business Rep ri Tide 115 I (�0 PM `� O PM <br /> L _w {�It K.Ch'`�O_t�l�1 �15er11f'cn. 11LI J <br /> J � � Operational Status Tire type Business Role Storage Type <br /> 4 j I (Fill one only) (Fill all that apply) (Fill all that apply) (Pili all that apply) <br /> Tire Count(Whole/PTE) I <br /> 0, L -.L. J't__ ! Q Active Q <br /> I I I I vv <br /> ® Pa <br /> Q Generator Q Outdoor <br /> NfN <br /> Latitude Closed Q AlVA 44 rJ�GPS Q Trck0Hauler 0 Indoo <br /> Longitude Q Inactive <br /> Q Planned Q OTR 0 End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q 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 INFORCEMENT STATUS: ," <br /> -tV A",;•HAULING AND MANIFEST REQUIREMENTS' Q Notice Of Vlolatron Q Erctension� <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires i V71 <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. ComplianceDes adlineI- ►' <br /> •• <br /> Q Q PRC§42956-Registration/Decal in Vehicle , <br /> Q 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date I, <br /> 14 CCR§18459.1 -Tire Program ID Number from CalRecycle m m ". <br /> O 0 (Required for NOV or EX7) <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years s <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCA§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance=No Violations o <br /> 0 0 Other:§ <br /> Comments _ 45 � l S ' 101-0 <br /> Inspection Form Included: Q <br /> m Include ��4z <br /> Co ments BPhone Number Ins tor's Signature:. Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: IEIXIAIMIPILIEI11 12131 62081 <br /> White Copy:CalRecycle Yeltow Copy:Operator Pink Copy:LEA �� <br />