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Waste Tire St... Bey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 m 12 4 2 2 8 `' <br /> Ccyclin and <br /> cover (CO) Survey Form _ gage 1 L <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: D 5 Cl l 5 J 0 Routine a Re-inspection 0 Referral 0 Observation <br /> Local \ ` If Referral,choose referral type(Fill one) <br /> Identifier: J et Lt,'V wG 0 CHP 0 CalRecycle 0 Complaint 0 Educational.Visit 0 Other <br /> Business or Facility Name 111 Inspected By Inspector <br /> Physical Address -/ I b l A A n es <br /> �/�v <br /> p ^ `` Inspection Date <br /> i f M Com` �J` C� Time In Time Out c <br /> Business Rep Title 4@ AM ®AM <br /> / 0 S 0 P ( d 0 P <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 /> It Active 0 Passenger ® Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 19 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 Notice Of Violation � Extension <br /> O O <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 /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <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 /> a <br /> 0 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 /> Q1 0 1 Other:§ <br /> Comments <br /> Inspection Form Included: 0 �aq fqq <br /> Comments Included: <br /> Business Rep's Signature Phone Number I p toy's'9(gn9lure Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pi <br />