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Waste Tire Suit iey & Inspection Report inspection Report Number ■ <br /> CalRecycle State of California( I 1 - 1177652 <br /> CalRecycle ndR(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- 1 1 L - ' Inspection Type(Fill one) <br /> Site Suffix: 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5 .r �� �vr�+/ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> CJ. b <br /> Business or Facility Name Inspected By Inspector <br /> 'address \«5 <br /> Physica39 U_ <br /> ��d F0. 2 <br /> �c 2 Inspection Date - / 2 7 t 3 <br /> �0.��'.e-Ccs <br /> C 7 J 3 J <br /> Time In Time Out <br /> Business Rep Title C O AM O AM <br /> Q 1 5 QPM 1 QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) ' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> Nle <br /> G <br /> PS Latitude o • Closed Q Altered <br /> 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 /> 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 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 Q 0 Notice Of Violation Q Extension <br /> 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 / mco <br /> / 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 O Referred/CalRecycle Enforcement <br /> 2 <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 /> z <br /> Comments <br /> Rauk,%Nt_ <br /> woS h wed V:p]� r5 dt d.CP_A5 Cs� Cove�r2rY1 <br /> lJcr�J2S: 8�S O Tim!; o"r ' yRor. 'Ti �C �4 rt YLn \byn4fZr oprraA-Z <br /> F Q. V i l i `0L t2�s <br /> Inspection Form Included: <br /> Comments Included: �liS�o'�o0 Za9-`�6$-3ZS <br /> Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:0 Incorrect: 7X*7v]IEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />