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Waste Tire Sup Bey & Inspection Report . Inspection Report Number <br /> calRecycle State of California T — ('y (� <br /> CalRecycledR(Rev.Recovery <br /> Survey Form - Page 1 g 1210 3 0 <br /> Dept of Resources Recycling and Recovery(calRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I r -3 � � � q o O � Inspection Type(Fill one) <br /> Site Suffix: �j 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: _1 - <br /> a w\ J Cja�4-V t h �V y/ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ,//! Inspected By Inspector <br /> O\ Cdw."eCq - l O <br /> Physical Address M ATSv <br /> �'Ioc� Wash e.c � — <br /> Inspection Date � / Z <br /> sA-oc� koV" CA SZ C>9 <br /> Time In Time Out <br /> Business Rep Title , U AM O AM <br /> I � 1 O 0P I _2 � � 1P PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) Z <br /> Active Q Passenger • Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned 0 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) 64 GICLOr <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 Q Hauler Q Agriculture Q Shredder 0 Other <br /> plrwhn v VLA <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 Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 EX7) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 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 In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> - z <br /> Comments 17 ���- __ �c��l e_ i�f' 1KS eC � Ov1 'CL►iS �Gl N <br /> - <br /> }VO \)-%h1CA. OVO Qr t'e..as cr� C6✓t_c_ <br /> Inspection Form Included: 0 z0f) <br /> Comments Included: • r 3 V® Z0q -/62-3Zgy <br /> u ness Rep's gnature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EXAMPLE 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />