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Waste Tire S*vey & Inspection Repor .. Inspection Report Number <br /> D'apt of CalRecycle ours Recycling and Recovery(CalRecycle) Survey Form - Page 1 11 - 12102 5 0 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- inspection- O , Inspection type(Fill one) <br /> ILIl � , �Site Suffix: 1 ®Routine Q Re-inspection Q Referral Q Observation <br /> Localc '� If Referral,choose referral type(Fill one) <br /> Identifier. I x-A vl 1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 5W Inspected By Inspector <br /> Physical Address LOJ_d <br /> �� �UZ� <br /> Street <br /> Inspection Date I 1 8 r 3 <br /> Q s�30 T <br /> City- State 21P Code Time In Time Out <br /> Business RepiCFGit(�dttral lol'+Dr [;�� <br /> :[;J�] <br /> 0AM m ®AM <br /> YL� �r,ncGS 0 PM (� (� J O PM <br /> L` — �"'�� Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Counthole/PTE <br /> • � ) Q Active Q Passenger ® Generator Q Outdoor <br /> GPS Latitude f O 0 Closed Q Altered Q Hauler .Q Indoor <br /> LTJ <br /> O Q Inactive ® Truck <br /> Longitude - FTFTF I I Q Planned Q OTR Q End-Use Q Container' <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer -Q Auto Repair 0 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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I <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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 44 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date I I <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),, <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 /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: p Violations' <br /> o <br /> Q Q § — to Com Mance No U. <br /> / z <br /> CommentsAl. UYt�z;-� 0,1 a <br /> _711446 Al vru 6re�jli <br /> b . vo.- - <br /> Inspection Form Included: Q <br /> Comments Included: - — d <br /> Bus ess•Rep's Sig Phone Number In p tso ig ture Phone Number <br /> INSTRUCTIONS ON BACK Corre /ncorrect: �J E X AIIVWLIEI 1 2 3' <br /> szoaii <br /> White Copy:Cal le Yellow Copy:Operator Pink Copy:LFA <br />