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Waste Tire A&Y & Inspection Repor spection Report Number <br /> Cal Recycle State of California 11 - 1176649 <br /> CalRecycle 1811Rev. y(Cal 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- Inspection Type(Fill one) <br /> Site Suffix: q 6 7- Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � Yu Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �' Inspected By Inspector <br /> �Cf } m S ( f e e s W�tee l <br /> Physical AddressS CA <br /> Inspection Date G) / 'z <br /> Time In Time Out <br /> Business Rep �/ TitleO AM Q AM <br /> PMPM <br /> 'A" 04 r�G(,Llr OWAC-C $ - O -- ® <br /> -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) g (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 •7 Active <br /> ® Passenger ® Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS 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 /> -- - ------ -- - -- --- ---- ---- — 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / 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 EXE 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 /> 7 <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations <br /> p /z <br /> Q Q Other:§ <br /> z <br /> Comments DMI 4-4Abc <br /> t Icrw i 14-zl n C)!G-A <br /> Inspection Form Included: O <br /> Comments Included: III <br /> Business Rep's Sign r Phone NumberIn'spector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X A M L E 12131 62081 <br /> EIIIWhite Copy:CalRecycle Yellow Copy:Operator Pink Cop : <br />