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Waste Tire Skey & Inspection Repor, Inspection Report Number <br /> CalRecycle State of California I 1 - 1230106 <br /> CalRecycle 181 Recovery <br /> „o► 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- t ' r, - O ) Inspection Type(Fill one) <br /> Site Suffix: ` �I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �-- t If Referral,choose referral type(Fill one) <br /> Identifier: S4(� J O Ck,61kA-j n COun� , 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> N` \) (k-n ("dl� A <br /> Physical Address LQ�� <br /> cc Inspection Date <br /> L� <br /> Time In Time Out <br /> Business Re\\p,,AA nn Title 0 O AM J(� O AM <br /> �C,�`U\ `71��1f1li11 OwnRf' 0 PM 8 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> o (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> g O <br /> ® Active ® Passenger ® Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 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 ® Other TT41u, (gyp>rt:1- YI J4 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 § - 0 Notice Of Violation 0 Extension <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 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 EXE N <br /> v <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 0 Other:§ l I ^_ �, <br /> Comments ,(.tl �fel 'fT-1 <br /> �U V i � ►U��1�tnS bJ <-tfe�nS 0� CcnLerl�� <br /> Inspection Form Included: 0 � ��� <br /> Comments Included: ® VUVvyW✓ v `� _ <br /> Bu i ess R s Sign ure Phone Number Ins ctor's Signature Phone Number <br /> __]JINSTRUCTIONS ON BACK Correct: Incorrect: EXAM 62081: 1 2 3 . <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />