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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1230152 <br /> CalRecycle (Rev.y(Ca), 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- i 3 Z - C) I Inspection Type(Fill one) <br /> Site Suffix: ` _L 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local ^ ` If Referral,choose referral type(Fill one) <br /> Identifier: ;,� col „7 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 7 Inspected By Inspector <br /> Physical Addrq§v 3 y <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title M OAM <br /> ! ) : 9 S O PM �.0 PM <br /> Operational Status Ti✓re 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 /> i` Active Q Passenger • Generator Q out <br /> O Q Closed Q Altered AJ <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned i& OTR Q 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 p�,C_! \\..Az�v--A <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 40 Other 6/,J U-� 0\,Z <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 EX ) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> w <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 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 /> Ivy,;� ,��o��i�c��; .�s, � ��c�►�1 <br /> Inspection Form Included. Q rinspe <br /> Comments Included: Busines ep's Si ature Phone Number or's Signa re 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 />