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Waste Tire Sui Bey & Inspection Report <br />CalRecycle State of California <br />Ccyclin andle R (Rev. y (Cal Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Part A - Survey <br />Inspection Report Number <br />11 - 1210196 <br />BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />Inspection Type (Fill one) <br />TPID -Inspection � � � � Z O I <br />Site Suffix: 'I <br />62081 <br />40 Routine Q Re -inspection 0 Referral Q Observation <br />Local <br />Identifier: J dQq U �O V ,r� <br />( <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Business or Facility Name <br />Inspected By Inspector <br />Physical Address <br />G 1 1 L M A -T I J <br />b2CD S, � <br />- - - -- <br />S c� �lS2oS <br />V) C%% <br />Inspection Date -7 <br />ut <br />Time In Time Out <br />Business Rep Title <br />q c * AM ® AM <br />C[ y 1 Q' <br />eSvS___�va`b C�w��t <br />J Q PM 0 PM <br />- - <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE)(Fill <br />one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(FII all that apply) <br />' <br />Q Active <br />Q Passenger <br />Q Generator <br />Q Outdoor <br />O <br />GPS Latitude <br />0 Closed <br />O Altered <br />16JA' <br />)0fl'� <br />Q Hauler <br />MA <br />Q Indoor <br />o <br />Q Inactive <br />0 Truck <br />Longitude - <br />Q Planned <br />0 OTR <br />0 End -Use <br />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 0 Other Wlr`1 th'TI <br />Part <br />B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />Notice Of Violation Extension <br />O <br />O <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />O <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date M / Ffl / m <br />O <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />O <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />(Required for NOV or EXT) <br />Q <br />O <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />O <br />O <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />O Referred / CalRecycle Enforcement <br />O <br />O <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />O <br />O <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />In Compliance - No Violations <br />Q <br />0 <br />1Other: § <br />- <br />i_ p <br />Comments <br />Oil <br />Inspection Form Included: Q <br />q _ <br />20- q� � <br />Comments Included: <br />"_ <br />Busi - 's Signature Phone Number <br />0 <br />INSTRUCTIONS ON ACK �Correct:40 <br />White Copy: CalRecycle <br />Incorrect: <br />EXAMPLE11121-3] <br />62081 <br />Pink Copy: LEA <br />Yellow Copy: Operator <br />N <br />Lo <br />0 <br />Lu <br />Lu <br />