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Waste Tire S,.Ivey & Inspection Repori. Inspection Report Number <br /> CalRecycle State of California I 1 a 12101- 19 <br /> CalRecycle cover (CalRecycle) <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- ( Q I Inspection Type(Fill one) <br /> Site Suffix: Q Routine ® Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. , 1 ��^ may, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> I �s m 1 U ) Es t,0� <br /> Physical Address <br /> i <br /> 3120 N , l� s II n LA) <br /> V- Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM �1 O AM <br /> ® <br /> 1 J ' 0 V PM �/ ® PM <br /> n Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) f 0 (Fill one only) (FII all that apply) (Fill all that apply) (Fill all that apply) <br /> ' \Q ® Active ® Passenger ® Generator ® Outdoor <br /> GPS Latitude Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR End-Use Q Container <br /> Business Type(Fill all that apply) <br /> wTre Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXn <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 /> ui <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 t7i r S� 7r U-.n 711113,1 ' 0±1N <br /> _ -4�i S CJS Ul ��� UAJ-V A,,i �'1 s Nj <br /> _- <br /> Inspection Form Included: O <br /> Comments Included: QQ – ` 1 �+—d' <br /> usiness Rep's Signature Phone Number In ctor's Signature_ Phone Num er <br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect: gjEjXjAj.MjPjLjEZ 1121362081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy: ® ■ <br />