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Waste Tire Sup Bey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1196585 <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- O � I � _ � ` Inspection Type(Fill one) <br /> Site Suffix: b tj 1 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> j <br /> Identifier: JdnV%Y\ Cov��c/ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name `, Inspected By Inspector <br /> Acevc ,s _ I l <br /> Physical Address o AA�\-Tfiy <br /> ��32 '�. C�.cco�e� �-c�-• <br /> Inspection Date I 2 2 1 3 <br /> oc. ova q S2o� <br /> Time In Time Out <br /> Business Rep Title <br /> t,, 0 AM 0 AM <br /> � r� \� J<• I"AVI S PM © 40 PM <br /> M <br /> ` � �c�> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whol TE 3 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator • Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 9 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 Q Extension <br /> Q Q <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 O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7J <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments V��'t1e— \M_r70 �+C2 _,QRQeC'NOC NMMe nvN <br /> CK S C &77 coY\ce C V1 <br /> Inspection Form Included: ' <br /> Comments Included: 10111 <br /> - �� 251- 6? <br /> I usin s Rep's Ignature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect: X 4 V E X A M P L E 111273 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © . <br />