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41 <br /> Waste Tire Sul►vey & Inspection Report Inspection Report Number <br /> calRecycle State of California 11 - 1242528 <br /> CalRecycle 18t(Rev. (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> part A-Surv _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- .�1 ' q © ( Inspection Type(Fill one) <br /> Site Suffix: G a Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: solo JoCkju>,,_\ Utl 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Busine//ss or Facility Name rr (� t1 Inspected By 1 Inspector <br /> PhalAddI C( �1�ns Mc•lie�lt�1()CQi - l O L <br /> Cs Como <br /> 200n 1 <br /> t 3 12 / Inspection Date 1 a / O <br /> Time In ` Time Out -I <br /> Business Rep Title p C '* AM 0 AM <br /> 0 PM 0 PM <br /> rl-N Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) !1 C (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> d, J ® Active 0 Passenger 4D Generator ® Outdoor <br /> O 0 Closed Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O 0 Inactive ® Truck <br /> Longitude - 0 Planned ® OTR 0 End-Use ® Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet • Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments &-W�l 09— .t N(q 'n.."fl t4 1 n l(v-� U�13/�- l -�Ws A'ut` Ulna``l'J <br /> Inspection Form Included: 0 (2v lN1(A-,l17g <br /> Comments Included: J "l <br /> Business Rep's Signatur Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ( EXAM L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: EA �� ■ <br />