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Waste Tire Sufey & Inspection Report inspection Report Number ■ <br /> Cal Recycle State of California I 1 - 1230198 <br /> CalRecycle 161 cov(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- Z 6 7 C� 5 - O / Inspection Type(Fill one) <br /> Site Suffix: / O Routine Q Re-inspection Q Referral Q Observation <br /> Local /� If Referral,choose referral type(Fill one) <br /> Identifier: 242_ Cptt�tun C� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address 3 9 - S�I,� C7;/!// 0✓A <br /> ,;23,U <br /> Inspection Date / J / � 7 <br /> Time In Time Out <br /> Business Rep Title AM AM <br /> G Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active 0 Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> C Q Inactive • Truck <br /> Longitude - Q Planned Q OTR 0 End-Use ! Container <br /> Business Type(Fill ail 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 • 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 Q PRC§ Q Notice Of Violation Q Extension <br /> 42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments /` 7Yu i r�✓��"�j ioi� 1 �QN c2c«� ?yo LG/c� /Z--- <br /> v <br /> �/a cou a" � cup /U 'fz on �� �/ >�ry, . l/r'o�•� n n . <br /> Inspection Form Included: Q <br /> Comments Included: Q � <br /> Business Rep s Signature Phone Number Inspector's Signature Phone Number <br /> • zN / / � I I I 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: �/ E X A /V1 1 2 3 ■ <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink py EA �� <br />