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Waste Tire Su,-vey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1210489 <br /> Ccyclin and <br /> (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- 5 1 3 _ "� Inspection Type(Fill one) <br /> Site Suffix: t v 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �— 1 If Referral,choose referral type(Fill one) <br /> Identifier: �l Jam U► n C ()L( 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> �S u L-¢_ <br /> Physical Address <br /> lC� �153Zb Inspection Date '5 <br /> Time In Time Out <br /> Business Rep Title 5 O AM 1 0 AM <br /> n ® PM p� l 6 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) X <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> Latitude 0 0 Closed 0 Altered NM <br /> GPS 0 Hauler 0 Indoor <br /> 0 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 0 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 /> 0 Notice Of Violation Q Extension <br /> 0 0 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 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 /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years Ln <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 O In Compliance-No Violations o <br /> 0 1 0 1 Other:§ <br /> Comments ; ) <br /> !) l_A eS `n CII <br /> 11m.ri�0.L1� 1 V J r'(1 <br /> Inspection FormIncludedti ��S�6 '- I✓ V - c1 <br /> Comments Included: ® a�1 9C - <br /> iness Number ep Signature Phone Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ( E X A E 1 2 3 1 <br /> 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Ay:LEY <br />