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Number <br /> m <br /> 02 I Inspection Report Nub ■ <br /> Waste Tire Survey Inspection Report, <br /> _ _ - <br /> CalRecycle State of California p� I 1 - 1245352 <br /> CalRecycle cover (CalRecycle) Survey <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- Inspection Type(Fill one) <br /> Site Suffix: Ll � i <br /> � 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: � Gas OI y-1 GU ✓t- _-1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical WressJ I_�f <br /> L SAS j Wv 6e_R" <br /> —� •' Inspection Date I / ( 6 I � / <br /> Vl-kCCA,_ <br /> ---— -- -- - --- - Time In Time O_ut <br /> ' Q AM Q AM <br /> Business Rep Title f <br /> 7— �J1 ® PM * PM <br /> ✓��� �'� <br /> YJ L)tS Operational Status Tire Type I Business Role Storage Type <br /> ` (Fill one only) (Fill all that apply)I (Fill all that apply) (Fill all that apply) <br /> Tire Count Wi)e/PTE) 9 16 <br /> Active ® Passenger Generator 0 Outdoor <br /> Q Closed Q Altered <br /> ��� Latitude � Q Hauler Q Indoor <br /> D Q Inactive 0 Truck <br /> Longitude - End-Use Q Container <br /> Q Planned 9 OTR <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair Q Trucking Fleet Q.Government 0 Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection 0 Crumb Rubber <br /> kr2t L <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other 0 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS O Notice Of Violation 0 Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> O 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> a <br /> O ® 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> LU <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Wn Compliance-No Violations o <br /> O Q Other:§ <br /> Comments ri�•L�- fit. t ��Ciy1 C Inp, on <br /> ct. OW <br /> Inspection Form Included: Q - Li Z 1 z <br /> "� <br /> Comments included. ~ <br /> Business Rep's Signature Phone Number Inspe or's Si ure Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK <br /> Correct: Incorrect: � � V EXAMPLE 1 12 3 <br /> -____ Whi+e('.—• Vollnim(xim-Onaratnr Pink Cocm LEA ■ __ <br />