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■ Waste Tire i, fey & Inspection Reporb. Inspection Report Number <br /> CalRecycle State of California( I 1 - 1178012 <br /> CalRecycle t8l(Rev.y(Cal Survey Form — Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey V <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ 0 1 Inspection Type(Fill one) <br /> Site Suffix. {1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� J d� Ut!1 01/l n \ 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> L0K�MA( rt4rfos � _ <br /> Physical Address o ES A lJ <br /> I <br /> Cc � <br /> . <br /> U\ �O� �� � `S�l � Inspection Date <br /> O <br /> \YC_J ! Time In Time Outl <br /> Business Rep TitleAM ®AM <br /> 1 O Q PM �. O PM <br /> oQ. �OmVUTAN <br /> - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) a 5 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger ® Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive ® Truck <br /> Longitude - 0 Planned ® OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0Hauler 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 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 m / m / m a <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 /> PL <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years _ <br /> 0 <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> n <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <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 <br /> A)I\S�a4 A) S n Vt U�'- <br /> ill aU; IU}�� DIJ � r��s r (mon Ce,1 n <br /> Inspection Form Included: 0 <br /> Comments Included: ® a <br /> Business Rep's Signature Phone Number nspe is Signature Kone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: EXAM L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L ■ <br />