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Waste Tire S tey & Inspection Repor Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1255861 <br /> CalRecycle 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— -7 <br /> � � � � � 1 Inspection Type(Fill one) <br /> Site Suffix: 1 I * Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP OCalRecycle 0 Complaint OEducational Visit OOther <br /> Business or Facility Name Inspected By Inspector <br /> 6ATc r O 1 f� 1 v <br /> Physicall Address <br /> 70 7 S_ C 1^c c-a 1�...e_e_ �. V, <br /> Inspection Date 2 / d Q / <br /> Time In Time Out <br /> Business Rep Title O AMQ AM <br /> O <br /> PM � � s� ® PM <br /> r' Operational Status i Tire Type Business Role Storage Type <br /> I <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 40 Active 0 Passenger • Generator ® Outdoor I Z <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 9 Indoor3 <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR O End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 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 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 <br /> 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 E?CT) <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/CalRecycle Enforcement <br /> f <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 <br /> O 0 other§ <br /> Comments e <br /> e_ �n�S �a c5�►1 <br /> Inspection Form Included�jq r v ( .113- &C> I -: c ' <br /> Comments Included / vJ �' l J "� <br /> u mess Rep's Signature Phone Number In�+br'sSignature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: E X AMPLE 1 2 3 62081 <br /> W1kte y:CaIR ycle Yellow Copy:Operator Pink Copy:LEA <br /> r <br />