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Waste Tire Sui Bey & Inspection Report inspection Report Number <br /> CalRecycle State of California I 1 - 1230061 <br /> CalRecycle (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- 2� 1 Inspection Type(Fill one) <br /> Site Suffix: ? $ 5 / I 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: \J OQ V CG vA(\ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> C .a k v N1$T 1 U <br /> Physical Address <br /> Inspection Date <br /> OZ 1 <br /> � <br /> Time In Time Out <br /> Business Rep Title Z O AM L, O AM <br /> ' O O PM / a PM <br /> Y.V e_ A\ 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 /> �O Q Active Q Passenger Q Generator Q Outdoor <br /> O 0 Closed Q Altere o /WA- N� <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q TrucP <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 * Other W � COtFT Ohs t` <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <br /> Q Q 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 Q Other:§ <br /> Comments�Vl� Y": �S <br /> 't1n2 Y-C W�S w`o�Q • <br /> CohC'2C e\ <br /> Inspection Form Included: Q � <br /> Comments Included: 0 }) It 'L <br /> Business Rep's gnature Phone Number Alnspeor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E I X AMP62081LE 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />