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Waste Ti#Su.vey & Inspection Ret._r , Inspection Report Numb&.r <br /> State of California <br /> CalRecycle 11 - 1245196 <br /> CalRecycle 1Rry(Rev. (Cal Survey Formol - 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- 1 /, -7- � 34 � _ 0 ' Inspection Type(Fill one) <br /> Site <br /> Site Suffix: �( ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. V} Jdaq v(yk 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Busin s or Facility Name 6 <br /> r. Inspected By Inspector <br /> � /� y <br /> Physical Addresd l o/ <br /> 1 0,�Lx ) / <br /> T`I'�/ - C/! ! 5-3 Inspection Date ' ( ) / ( / 1 S— <br /> Wc� Time In Time Out <br /> Business Rep !� Title � Q Q AM Q AM <br /> PM 0 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Counthole/PTE) / �( (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> T &Active 0 Passenger &Generator 0 Outdoor <br /> 0 <br /> GPS Latitude 0 Closed 0 Altered <br /> Q Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> I <br /> Business Type(Fill all that apply) <br /> 4b New Tire Dealer !Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 41 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 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 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 /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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) <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 /> 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 ®(n Compliance-No Violations o <br /> O Q Other:§ <br /> Comments -7- . I <br /> f.�--� �- k-Q, l�G r W eil'�ci A <br /> Inspection Form Included: 0 �- <br /> Comments Included: 0 <br /> Business'Rep's Signature Phone Number nspector's Signa Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />