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Waste Tire Sr... Jey & Inspection Report inspection Report Number <br /> CalRecycle State of California I 1 - 1176789 <br /> CalRecycle (Rev.Recovery <br /> 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- � �j � � - D � Inspection Type(Fill one) <br /> Site Suffix: ` • Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local n If Referral,choose referral type(Fill one) <br /> Identifier: l(� fl �i ►� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address v I Ren Eszofo <br /> Inspection Date 9 <br /> Time In Time Out l <br /> Business Rep Title le AM h • AM <br /> I 9 ' So O PM 0 ' I D O PM <br /> — - -- - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) �j' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> iC/ ® Active 0 Passenger ® Generator 0 Outdoor <br /> O 0 Closed 0 Altered 1 td/A <br /> GPS Latitude 0 Hauler 0 Indoor <br /> p 0 Inactive 1* Truck <br /> Longitude - 0 Planned ® OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 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 ® Other lJl 'l I bLL��f f <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 0 PR - 0 Notice Of Violation 0 Extension <br /> C§42951 Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> 0 41 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 /> a <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 /> W <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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:§ I <br /> Comments n rl I ki(\I- �}'..L,�2 .��1 e� 1 Sl ' �51��) /l 'P jv)a <br /> Inspection Form Included: 0 79, <br /> / zap• - -- <br /> Comments Included: <br /> Business Rep's Signature Phone Number <br /> &Inspje �,Signature� one Number <br /> - m — <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X j� EXAM LIE __�l 12131 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink C y: <br />