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Waste Tirelurve & Inspection Re ik Inspection Report Number <br /> CalRecycle State of California Y _ <br /> - 1255725Caycling le18t(Rev.y(Ca[ Survey Form Page 1 I1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � p� � � �c=, _ � � Inspection Type(Fill one) <br /> Site Suffix: ( 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> _yvG IT'I✓�. <br /> Physical Address - U I{UL <br /> Inspection Date 6 <br /> Time In Time Out <br /> Business Rep Title f _ 0 AM l /� 6 0 AM <br /> ( L.� G QPM 1 V �✓ 0 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 /> 4&Active Q Passenger ! Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> O Q Inactive Is Truck <br /> Longitude - Q Planned Q OTR Q End-Use a Container <br /> Business Type(Fill all that apply) <br /> Q 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 Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station O Hauler Q Agriculture Q Shredder Other Tl <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 Q Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / M / 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 EXE C11 <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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 9 In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments����;YVl.._. <br /> aluLao <br /> Fpectionorm Included: Q � ��,^Vents Included: ® ,4t <br /> Busine s Rep'sIgnature Phone Number Inspect 's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: errect: <br /> , 1� q �FEFxl ATmTP � L� Ej 111273 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />