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Waste Tire Su. Bey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1196363 <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- Q - © Inspection Type(Fill one) <br /> Site Suffix: 41 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SCS JCet1A I �n ^ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _ _` Inspected By Inspector <br /> Tr?-k� 7o-�Otr-' 39 - 1 0 <br /> Physical Address CSGdTTO <br /> D-Ut5 N ni r-1- ", <br /> � � CA SQv'i Inspection Date( 1 <br /> Time In Time Out <br /> Business Rep Titlec 0 AM I 0 AM <br /> 1- 0)rr_.J0 ' 3+ I -I" I ) • J .S Q PM � � V O PM <br /> t'La_. �a' 1�1�W d �f-f fr 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 /> 0 Active 6 Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q 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 ® 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 a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXTJ <br /> Q O 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 I&In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> Q.v VA� -j-, vJ q II i 1 } I _},� v 'Vl c. 11 n S� e t)-\ Lam. w i r 11 S CJS � � 'y n 61 1 yl-_ <br /> ! 1 =1 _ <br /> Inspection Form Included: Q � <br /> Q l Cil _ <br /> Comments Included: � <br /> Business Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect: k* �� JEJX�AJM L E - 1 12131 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy L © ■ <br />