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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of CaliforniaCalRcycle11 - 1229965 <br /> Dept of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ( r76 S / - I Inspection Type(Fill one) <br /> Site Suffix: b 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: c t� <br /> �CjOL V Y\ LO Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> 0 Inspected By Inspector <br /> Physical Address <br /> /�� C �SZos Inspection Date U 3 / l , <br /> S � �� Time In Time Out <br /> Business Rep Title c , SAM i 0 AM <br /> � PM ` � d � �PM <br /> �v4c,c\-0 �Qaw"vtjz ©Wr'_(- <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 /> Q Active Q Passenger Q Ge`nerrator Q Out or <br /> O 10 Closed Q Alte ed "/�v(* <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all 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 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 /> Q Q PRC§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 /> QO 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q O 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 EXT) N <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 /> Uj <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ —_ W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance No Violations o <br /> Q 1 Q 1 Other:§ 1` `` '_A <br /> Com ,4ments�N` CO 'V�S \C�h �v�2 Oh iS � Qr"IS 'fOMa%'r ' h0'tC9.`• <br /> 5121 <br /> !in2 v,.b kbvt Ib <br /> cw\. "-D ��CS Grn 'D CIO, <br /> Inspection Form Included: Q <br /> c �r� <br /> Comments Included: O <br /> Business Rep's Signature Phone Number Inspect is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: YOC NJ EjXjAjMj PILI El 11 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />