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T <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California — <br /> CalRecycle <br /> and!R cover (Cal Survey Form - Page 1 I1 1230292 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � O � !„ r+, � � O Inspection Type(Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sam J 0Ull r1 1 �'1 — 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> 6* Lo5►':Jl c s <br /> Physical Address <br /> o <br /> 1 1 CA S�bs Inspection Date I l 5 <br /> ��1 v(NIS r� J <br /> Time In Time Out <br /> Business Rep Title O ' O 10 AM <br /> O PM 0 O PM <br /> S�(A <br /> Q)r\ 1 P `0rC11CT 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 /> 0 e Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered P I A <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive ® Truck <br /> Longitude - 0 Planned • 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 wo tVEMSP. <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 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 EX7) <br /> N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> Uj <br /> W <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance-No Violations o <br /> 0 0 Other:§ z <br /> Comments IK�U��11�a �(J1/� G"�•\ 1nS u (�bJV' L t (ka�-I� <br /> to I <br /> N o V►of��-Ls n t ca.��s ����,n(�� <br /> Inspection Form Included: 0 /„�/� ' - <br /> Comments Included: s <br /> B si ess Rep's Signature Phone Number Ins a tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X Amw � <br /> 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink ® ■ <br />