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Waste Tire Ste & Inspection Repot*Inspection Report Number <br /> CalRecycle State of California Y <br /> 9 Ccyclin andR(Rev.Recovery <br /> Survey Form - Page 1 I1 1196702 <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: 0 ? ? L. q ®'' 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: N-\ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> C. M&A(9y\'e.y,f �`y 1 <br /> Physical Address 6 v ` I � TQ <br /> Inspection Date \ 2- <br /> Time In Time Out <br /> Business Rep Title p O AM O AM <br /> cvv <br /> 1 � ® QPM ` � ' QPM <br /> c1c.. �e.o�e��A. �,nS. �, <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whol <br /> ® (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> PTE) <br /> 0 Active • Passenger ® Generator 0 Outdoor <br /> O Q Closed 0 Altered <br /> CaP� Latitude ° 0 Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned 0 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 <br /> Q Service Station 0 Hauler Q Agriculture Q Shredder • Other pe^pvt1�%or\ <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 mm / 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 EX7) N <br /> a <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 <br /> In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> Inspection Form Included: Q <br /> -3z�`1 <br /> Comments Included: - - - - <br /> usiness R nature Phone Number Inspector's Signature _ Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: E X A M P L E 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />