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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 11 - 1245006 <br /> CalRecycle <br /> and R(Rev.y(Ca[ 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- 1 � 1 O K ' Inspection Type(Fill one) <br /> Site Suffix: (J ID Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q To 0',V t^ co n 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address b MA <br /> l S*2g0 S� MG�(�`� <br /> Inspection Date Q -7 , S <br /> Lu-�'�►.�o C 533 <br /> Time In Time Out <br /> Business Rep Title ` \ O PM I 5 O 0 AM <br /> 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 Pa/s(seeng-eer 0 Generator <br /> 0 Outdoor <br /> O .0 Closed 0 Altef�d` Aj`` i/' or1 <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 Q Inactive Q 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 <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 40 Other tw_ <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 /> 0 0 <br /> PRC§42951 -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 Date <br /> M / m / m <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 EXT) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> uj <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators *in Compliance-No Violations o <br /> 0 1 0 Other:§ <br /> Comment <br /> OV^S 6 C' VQ-0.S 4- C-0 tiCe f ss <br /> N t ac (� 1l Mr1q_CRX <br /> Q y <br /> Inspection Form Included: Q <br /> Comments Included: [o < ` 2 <br /> Business Rep's Signat re Phone Number InspecA�eignature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P L E 1112 3 62081 <br /> 11 opy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />