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2 Waste Tire dey & Inspection RepooInspection Report Number <br /> CalRecycle <br /> State atCalifornia I1 - 1242495 <br /> CalRecycle 781(Rev.y(C 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- C r Q © I Inspection Type(Fill one) <br /> Site Suffix: J �j ` ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: sgfl Ja r�o�i��� �U�'�► Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name "!! <br /> b77 <br /> Inspected By Inspector <br /> �� Sc.h w w� \ �� 3 - <br /> Physlcal Address s I l v <br /> aq 46 Inspection Date <br /> , ` of �A J Time In Time Out 111 <br /> Business Rep Title I O AM 1' O AM <br /> Uv"Y� LA <br /> 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> i 1 <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1-� <br /> ® Active ® Passenger 40 Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive ® Truck <br /> Longitude — Q Planned Q OTR Q End-Use Container <br /> Business Type(Fill all that apply) <br /> 10 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 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 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 / 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 Q 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 is In Compliance-No Violations o <br /> Q Q Other:§ l A <br /> Comments <br /> No y i L) u,7'11 un S (of &,_fe-y1S o�LU rltern <br /> Inspection Form Included: Q41q S^ k <br /> Comments Included: ` I "' <br /> Busl ess R s Sign ture Phone Number Inspe is Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � W EXAM L 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy.L <br />