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Waste Tire S ley & Inspection Repor Inspection Report Number <br /> State of California <br /> CalRecycle 10/10) <br /> 11 - 12155865 <br /> CalRecycle l8t(Rev.y(Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> TPID- y Inspection Type(Fill one) <br /> Site Suffix: I Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sam �L �- Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> ( Inspected By Inspector <br /> Inspection Date 7 <br /> Time In Time Out6 <br /> Business Rep Title *AM 0 AM <br /> 1 s Q PM ' I J `/ 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) l' 2 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> l 7 0 Active J& Passenger 0 Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> 0 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 10 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m FTI <br /> / 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 <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 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations = <br /> Q Q Other:§ (� - !— <br /> Commentsh \ham Gkhe— (Y' :S 1�— &A— <br /> � � S <br /> Inspection Form Included: 01 _�,4��3�� �q'" I 0,3 &l <br /> - <br /> Comments Included: 0 l <br /> Busi ss Rep's Signature hone Number nspe ors Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:41 Incorrect: JEJX�AIMIPIL�E1 1112N 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />