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Waste Tire Sup vey & Inspection Report 1rispection Report Number <br /> CalRecycle State of California 11 - 1210357 <br /> CalRecycle R(Rev.y(Ca[ 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- l' e a Inspection Type(Fill one) <br /> Site Suffix: 9 _7I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sa� 90 v n� OCHP OCalR�CalRecycle 0 Complaint OEducational Visit OOther <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address ATT <br /> c� Inspection Date 6 © 3 / 1 3 <br /> 95203 <br /> Time In Time Out <br /> Business Rep Title •AM 1 AM <br /> � O PM 1 a � � QPM <br /> Y\V <br /> _ � . coo C :'� �' <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 /> • Active 0 Passenger 0 Generator • Outdoor <br /> �PS Latitude O Closed 0 Altered <br /> 0 Hauler 0 Indoor <br /> o Q Inactive ® Truck <br /> Longitude - 0 Planned e OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer - 0 Auto Repair 0 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 ! 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 /> O Notice Of Violation 0 Extension <br /> 0 0 <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 M / M / m <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) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecyc(e Enforcement <br /> 2 <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 In Compliance-No Violations o <br /> 0 1 0 1 Other:§ <br /> Comments <br /> -Wows 0.5 - Vl.akec,\ 1 <br /> cii-Q- Cm rtce-�r1 <br /> Inspection Form Included: 0 <br /> 2a4-Y�8'-3Z$ <br /> 'A AAA <br /> Comments Included: Viry <br /> Business Rep's Signature Phone Number Inspe tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X �� E I X I A IMI P I L I E I I 12 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />