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Waste Tire Su. Trey & Inspection Report inspection Report Number <br /> CalRecycle State of California 11 - 1177850 <br /> CalRecycle 781(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- inspection 5 9 _ © [] Inspection Type(Fill one) <br /> Site Suffix: 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: Isan7o�hl Al( b V,(+ 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name I Inspected By Inspector <br /> �' tl\ GY' cx.S _2�,n�_ <br /> Physical Address Jj - C�C06 <br /> p <br /> �` a0 (A �JInspection Date , / I 1 / 1 3 <br /> Pl� Time In Time Out <br /> Business Rep Title /, r ® AM i C ® Al <br /> 'TOv1c, `J `J O PM J0 PM <br /> �vl�C,T V i 5nr <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 /> ' ' 1 d• 0 Active ® Passenger 0 Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive ® Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 9 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 /> 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 HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 - ®Notice Of Violation � Extension <br /> 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 3 <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 EXT) N <br /> a <br /> 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <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:§ <br /> Comments VC.0J rt_ V�1y1 C� �'�jc_ (ns 11"u, AAty` CIYI aQ . OL,t <br /> Sec. -e03-1� <br /> Inspection Form Include 0' 2,- <br /> Comments Included: ® 16 "�9VAhS <br /> Business ep's Signmber ature Phone NuInsp tor'.Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 70YK EXAM 11 12) 662081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink CoQy. © 0 <br />