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Waste Tire Survey & Inspection Repon Inspection Report Number ■ <br /> State of California <br /> CalRecycle I 1 - 1242491 <br /> CalRecycle (Rev.y(Ill) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> 'art A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- - OInspection Type(Fill one) <br /> Site Suffix: 41 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalI � ��� If Referral,choose referral type(Fill one) <br /> Identifier: < J Q 1/� •� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> q awe, �C C' L <br /> Physical Address 3 1 v i Cs�TTd <br /> �031S lAv� mUn - <br /> /1 1 rA Inspection Date <br /> 0p��,�0n C� "1SZIL 1 <br /> Time In Time Out <br /> Business Rep Title O ,l ®AM i I AM <br /> U <br /> CAQ PM ( Q PM <br /> S �al�.� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) r7 5 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 4& Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ® 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 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 _ 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 /> 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:§ 11 ll 1 ].l l <br /> Comments <br /> K. A nR_ww4�,A1.ry_ 1 (105,F ,uf\ . LU-Nj_ r)r�Yl� flr� 1 x, �A,21 1 va_ <br /> WUS Y- c a' <br /> Farm <br /> Inspection Form Included: 0 Y(zq)- 0 e-317L <br /> Comments Included: ® // ne s�is gnature Phone Number Insp ors Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Corre t: Incorrect: E X A M L 112 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop LE <br />