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® Waste Tire Su, vey & Inspection Report Inspection Report Number <br /> CHIRccycic State of California 11 - 1210161 <br /> CalRecycle 181)Rev. (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 Inspection Details <br /> TPID- Inspection o ` Inspection Type(Fill one) <br /> O <br /> Site Suffix: �j p lJ p ` 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �OQQ �;r c0 V // <br /> A� CHP 0 CalRecycle 0-0 Complaint Educational Visit__0 Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> - 1 � A <br /> Physical Address 0 !MI T T U <br /> C�S!n—C Inspection Date 7 / 3 / I 3 <br /> \-c->CA. `_O� L-417 C�J <br /> Time In Time Out <br /> Business Rep Title 0 AM o PM I Z 0 � O AM <br /> * PM <br /> 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 /> 46 Active 0 Passenger 10 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 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 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 � 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 /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 EXT) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> Uj <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 e In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments +�e <br /> C e <br /> Inspection Form Included: 0 <br /> Comments Included: a E, 4 ���-��� <br /> A� <br /> Business Rep' Signature Phone Number 41nspctor's Signature Phone Number <br /> -- _ - 62081 <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: X �t qjjEjXjAjMjPjLjEj 1112 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />