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Waste Tire Sul vey & Inspection Repor l. Inspection Report Number ■ <br /> State of California <br /> CalRecycle I 1 - 1226618 <br /> CalRecycle (Rev.y(CD) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Sart A- Survey___ _____ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I �n 1 - /, Inspection Type(Fill one) <br /> Site Suffix: 10 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Localsa, <br /> ] , If Referral,choose referral type(Fill one) <br /> Identifier: J Q(,ail�tA{tl (01LA -) V1 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name J Inspected By Inspector <br /> 6Qton l?;p,-, � cc��� <br /> Physical Address <br /> MM <br /> �l Ck ( A q 5 7 Inspection Date <br /> Time In Time Out / <br /> Business Rep Title I / 1 * AM /l Q AM <br /> —r`1 Pre b VI � U QPM I � • � V fa PM <br /> , WufmS�r1�\ � n1of Sn��_ <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> 8 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O <br /> GPS Latitude 0 Closed 0 Altered <br /> 0 Hauler Q Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 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 Q (h I <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 41 Other InjL4,e �iul `;(1, I�INf) U(,�, <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 /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> r <br /> e <br /> 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 /> 2 <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 10 In Compliance-No Violations o <br /> 0 0 Other:§ rr11.- l --II 1- <br /> Comments C4 n S, A k)tA7 _ ( <br /> S�C_�i F" ���J P Pi11 Z)fl r/lm-,of) ' ij� C/1,a�r z j-n +I'1 L- <br /> <11 e. ri Frwc,, <br /> Inspection Form Included: �I <br /> Comments Included: is —- <br /> Business Rep's Signature Phone Number/ Ins_ tor's Signature _ _ Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: ( v) � E�X�AJMJPJLJEJ 111213162081 <br /> . White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ■ <br />