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r <br /> Waste Tire S*ey & Inspection Report--IInspection Report Number <br /> State of California <br /> CalRecycle 10/10) <br /> 11 - 1230077 <br /> CalRecycle R(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- Inspection Type(Fill one) <br /> Site Suffix: Z 7 - , • Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local T� If Referral,choose referral type(Fill one) <br /> Identifier: S0.Y\ v�Y\, ( .. V�r�� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name l�� Inspected By Inspector <br /> dr L <br /> ! 0 r�c1k. L;rcS LLC <br /> 3 `�I - 1 C) <br /> Physicall Address <br /> 1 2 VA. S T.2. 1 <br /> C CI Cy <br /> CIN- q 5361 Inspection Date O N ' S <br /> I <br /> Time In Time Out <br /> Business Rep Title z 0 AM � 0 AM <br /> r^ d O PM ' ®PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger * Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O 0 Inactive f 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 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 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 0 PR §4295 - 6 Notice Of Violation 0 Extension <br /> C 1 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 Date0 7 / M15 <br /> 0 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 /> Lu <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments <br /> Lin:� <br /> c�s� �mx' Yoce <br /> Inspection Form Included: 0 Pp)\'Vo <br /> Comments Included: 0 <br /> si ep's Signature Phone Number Inspec or's Signature Phone Number <br /> �-,{ <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 7X7* �J E X A M P L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />