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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1210194 <br /> CalRecycle (Rev.Recovery <br /> 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- �^) -/7 Inspection Type(Fill one) <br /> Site Suffix: ` 0 -1 I 01 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 50'V\ J-0CL�p�� Y\ Cp V Y\. `, 0 CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l IJ Inspected By Inspector <br /> Physical Address <br /> Inspection Date -7 g 1 3 <br /> Time In Time Out <br /> Business Rep Title 1 *AMQ Al <br /> QPM I Z" 2 S QPM <br /> Llnttis Vc�.r. So��T �I,qv� e� <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 /> 0 Active 0 Passenger 0 Generator Q Outdoor <br /> Q Closed O Altered <br /> GPS Latitude Q Hauler • Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned O OTR O End-Use 10 Container <br /> Business Type(Fill all'that apply) <br /> 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 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 0 Extension <br /> Q O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> OO 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / M / 17 <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators e In Compliance-No Violations o <br /> Q O Other:§ <br /> Comments <br /> o"16 C via Co c tic <br /> Qc As�2.*_,s2 f h <br /> Inspection Form Included: Q <br /> Comments Included: * NIX - J 5 S /jjAp4_ %p%-%9-3Z J <br /> Business Rep's Signa ure Phone Number lnspeftor.s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: � � q� E X A M P L 'E 1 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />