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0 Waste Tire SL. tey & Inspection Repork Inspection Report Number <br /> CalRecycle State of California 11 - 1210341 <br /> CalRecycle lndRec very(v. al 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- , 2 \ 1, O 1 Inspection Type(Fill one) <br /> Site Suffix: 7 "1 IV Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> ^ ``�� <br /> Identifier: 0.r oM W yr y Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address Cp ?j —1 1 1 �(� v <br /> T <br /> 25 '77 W - 1;-,�osVv% <br /> 0.h T e_C0. C A C 5 337 I Inspection Date � / 07 <br /> CA 1 Time In Time Out <br /> Business Rep ` Title 0 � AM `� �AM <br /> �W�e\ O O PM ` V 5 PM <br /> 01 <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) Z (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger 4&Generator 9 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — Q Planned Q OTR Q End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair `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 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 <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 E)CT) n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> Q Q 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 In Compliance-No Violations o <br /> Q Q Other:§ <br /> CommentsV oV yse w 5N ve �,� CG�DNq %nP CyN. <br /> \�P V�c9�C>1S� L Y�G_� se-e-V C ND G`` _ <br /> s cec <br /> Inspection Form Included: Q ZQ It5L z 9 2-9 kM.4 2o9'-q6g-32$yComments Included: 7 J <br /> Busin Rep's Signature Phone Number Inspect or's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct:* Incorrect: x �t NJ I IEIXIAIMIPILIEI 111 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />