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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 11. - 1230329 <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- G l Inspection Type(Fill one) <br /> Site Suffix: u t I O Q Routine Q Re-inspection Is,Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Ste']�o wq CU�n Q CHP Q CalRecycle 9 Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> l <br /> Nv c&+P,r T 1 f us -rr� <br /> Physical Address 2 1 - V �� (/ <br /> / �{SUInspection Date 3 S S <br /> GA " S Time In Time Out <br /> Business Rep Titl(eYt,., 2 O O AM O AM <br /> U 5 fi�r �G�,Cf 1v ��`Sl�.i��1. cT � ® PM � � � �-PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) D (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 16 Active 9 Passenger &Generator I* Outdoor <br /> O Q Closed Q Altered <br /> �PS 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 /> _ New Tire 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 /> Notice Of Violation Q Extension <br /> ® 0 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 rr <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle J M15 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE h <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <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 Q In Compliance-No Violations o <br /> Q Q Other:§ n <br /> Comments ( f 5 (AnA <br /> tl\ 1� <br /> Sw .ry%n s Guru <br /> Inspection Form Included: Q A,—,(&�) 1' <br /> CommentsIncluded: ®0c � `�'���+ I�Gd:'�— 4w-3 O <br /> Business Rep's Signature Phone Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:I. Incorrect: g E X A M P L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />