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0 Waste Tire Sup vey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1196303 <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- Inspection Type(Fill one) <br /> Site Suffix: 1 -7 /— <br /> 7 � � � � Q Routine Q Re-inspection ® Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: C/)� �Ulr1'1,�j Q CHP Q CalRecycle Q Complaint ® Educational Visit Q Other <br /> Business or Facility Name / Inspected By Inspector <br /> l�Ct-n. LL L , _ <br /> PhysiF Address 31 LC l A r ,—m <br /> a0l T O <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> fA\C.%`ICA" 6VVL,_ w� � � . U 0 ® ® PM <br /> PM S C C> <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whol q) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q0 ® Active ® Passenger ® Generator 40 Outdoor <br /> O Q Closed ® Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q inactive 0 Truck <br /> Longitude - Q Planned Q OTR ® End-Use Q Container <br /> Business Type(Fill all that apply) <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 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 <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 EX7J N <br /> Q Q 14 CCR§18459.3-Fatention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Iv anifest 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 ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> Inspection Form Included: <br /> Comments Included: ® \V1n — _942!�-y <br /> Z_ff_ <br /> Business Rep's Signature Phone Number I p cto 's 7.gn ture Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: jEjXjAjMPj_LjEj1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />