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Waste Tire Su. fey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 — O I <br /> CalRecycle t81(Rev. (cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN_ <br /> BLpiness Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 00b 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SQA Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name •! <br /> Inspected By Inspector <br /> Physical AddressA <br /> 3255 i\tzv� etia,2c�_ Y <br /> Inspection Date Q <1 / I -Z / <br /> Tcci C CA �s3oy <br /> Time In Time Out <br /> Business ep Title t0e�N C O AM O AM <br /> I � �/ 0 PM ` ' � v ® PM <br /> �� e a � Cr r- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole T U (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ll�� ' 1 \A ® Active Q Passenger 0 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 0 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q 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 1 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other MICRM C.`-e_ DecA <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / 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 EXT) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> LU <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 1-0 Other:§ <br /> Comments <br /> K�nV��Y�-� <br /> Q h <br /> Inspection Form Included: Q A/, <br /> / �,r,Q��� ? j� Iq <br /> -z(�y6g_324 l <br /> Comments Included: / 4"/ `7(r' O <br /> Business Rep's S nature Phone Number Inspe Kc Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: ❑EXAMPLE 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />