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® Waste Tire Survey & Mspe tion Repo Inspection Report Number <br /> CalRecycle State of California I 1 - 1255793 <br /> CalRecycle (Rev.y(Cal p pfP�(ey ForfFi(�1 0 Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey V �f IIJJ tl�Il M <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Z c' —]_ Z _ Inspection Type(Fill one) <br /> Site Suffix: 3 J ]� J * Routine Q Re-inspection Q Referral Q Observation <br /> Local e—�, If Referral,choose referral type(Fill one) <br /> Identifier: --_.'4 Vj �� �`��VC.� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address (J 1 ` �1 i'f L•� L� <br /> l GX.t- <br /> Inspection Date <br /> s�(��� <br /> •tel Time In Time Out 1 J <br /> Business Rep Title T\ 0 AM Q AM <br /> 3 ' U <br /> L &PM k_) BPM <br /> ;Z Cam+;��� rn�� .�- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (6 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> LP� � � <br /> Active 0 Passenger ® Generator ® Outdoor 3 <br /> Q Closed Q Altered <br /> �PS Latitude Q Hauler Q Indoor <br /> o Q Inactive a Truck <br /> Longitude — Q Planned • OTR Q End-use ® Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 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 0 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 /> 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 EXT) N <br /> a <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> Comments 1 iM- �.1�Aft�u t✓ r��rL <br /> l�t"!r;_ (ter✓` `�t-MJ�`jc^ `I.�C�2G1 �'��St4 <br /> Inspection Form Included: Q _ 'W <br /> q#611 4&k—�_ 40 T\ <br /> Comments Included: 0Business Rep's ign ture <br /> Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X7*A E X A M P L E 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />