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Waste Tire Cr fey & Inspection Repot Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1176582 <br /> CalRecycle cover (cal 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- q Inspection Type(Fill one) <br /> Site Suffix: 3 S / ® ! ® Routine Q Re-inspection Q Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` Inspected By Inspector <br /> Physical Address Q <br /> f}y►-tt.�ic� 13dr.�H Com.... <br /> 4 r.k1r,,r f ocD e c. . <br /> Inspection Date 0 / o (L- <br /> Time <br /> / 1 <br /> �� cy s-21 <br /> �1 S Time In Time Out <br /> Business Rep Title <br /> ® AM / ®AM <br /> S_ 0 PM / C O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) j (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' Z ® Active ® Passenger ® Generator ® Outdoor <br /> GpS Latitude O Closed Altered O Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q 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 ® Other ti <br /> mGl2 !�-tinur_. C� <br /> - <br /> V A HAULING AND MANIFEST REQUIREMENTS - <br /> Part B - Inspection of Waste Tire Dealer Generator Hauler and End Use Facility ENFORCEMENT <br /> 0 Notice Of Violation O Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 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 N <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations <br /> Other:§ - -- -- _.__-.:_.------- - - <br /> - z <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: ® '1 7br12�'/7 4rC�-- ���,�Y��'°� Z� <br /> Business Rep's Signature Phone Number Inspector's.Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct 0 Incorrect: X E X A L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink C py:L <br />