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Waste Tire Swey & Inspection Reporiori . Inspection Report Number <br /> State of California <br /> I 1 <br /> 1230276CalRecycle 181(Rev. <br /> (Ca[ 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- O C, r, C, n - O Inspection Type(Fill one) <br /> Site Suffix: -1 L -0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5a yN IdC(_�v-,_ ��,h� ` Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> S v 3 C` I O 1 v <br /> Physical Addre <br /> 1 ZS -oc9.� 0.9 P_ <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title ,�•,� ` , : r�s O *0O APMM � 7 y�V Z O AM <br /> 1 108 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) t 2 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ID Active 0 Passenger 0 Generator * Outdoor <br /> Q Closed O Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 0 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 O 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 /> Q Notice Of Violation Q Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycleIn <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> O O Other:§ <br /> Comments 0�5 Fes_ h�('P ;r� C T1 DVS �c� Pez, 'Tlni s C 7.L k <br /> Cu dI <br /> Inspection Form Includedjus <br /> Comments Included � -Rep's Signature Phone Number Inspect isSignature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: zQ 7w q IIEIXIAIMIP I LJEJ 111213 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA �� <br />