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Waste Tire Sup Bey & Inspection Report inspection Report Number <br /> CalRecycle State of California I 1 - 1230075 <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 \ Inspection Type(Fill one) <br /> Site Suffix: ? S p 2_ Z 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: C�V.n 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Sir �6 V�Y\ <br /> Business or Facility Name ` Inspected By Inspector ,\ <br /> Physical Addresslr 2 —1 J"\A 1 v <br /> '1-7?7 (c-eev`�Rc' <br /> S (X Q,SZ�S Inspection Date I 1 S <br /> 1 Time In I Time Out <br /> Business Rep Title 2 AM 7 O AM <br /> ` PM 10 PM <br /> 5&' z re,.— t2{.DC.S <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 /> fi5 ' Active 0 Passenger .0 Generator 0 O,lutdoor <br /> 0 0 Closed 0 Altered /" <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned Is 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 40 Other 5� 1gV% 4N .*5 <br /> ,v�+ <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§429 0 Notice Of Violation 0 Extension <br /> 51 -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 /> 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) n <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 /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments'a <br /> v`S C C 0. v�c2C✓� <br /> Inspection Form Included: <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspe tor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P L E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />