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Waste Tire Su.vey & Inspection Report , Inspection Report Number <br /> State of California <br /> CalRecycle 10/10) <br /> 11 - 1230324 <br /> CalRecycle (Rev.Recovery <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Su_rve ry _. BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � _ � � Inspection Type(Fill one) <br /> Site Suffix: ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local / ] If Referral,choose referral type(Fill one) <br /> Identifier: Sin JOdI Cf t T Vc �tn►^� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> 5e,1- r� <br /> Physical Address b` 3 V l pco Tb <br /> Inspection Date � / ' 1 / 1 5 <br /> I..-in�'t'_� CA aSL}4 <br /> Time In Time Out <br /> Business Rep Title 0AAM- 1 O AM <br /> 1 0 LN l/ ®PM <br /> — Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) t (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 41 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ® Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -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 EXE n <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years N <br /> 0 <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <br /> w <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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:§ ] ],1 1,, <br /> Comments �ny'l Y ►�S C_ <br /> o S u (cac 4 Lunt.VIrn- <br /> Inspection Form Included: 0 S<j�v( ri✓ 4/ iG �' / �Signtur, A,Comments Included: e 1- �� '3Business Rep's Signature Phone Number Insp Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E I X I A JMPA 1 1 2R <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:I kv <br />