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Waste Tire bui►vey & Inspection Repos L Inspection Report Number ■ <br /> Cal Recycle State of California I 1 - 1226671 <br /> CalRecycle <br /> ndR(Rev.Recovery <br /> 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- I C I („ () - © I Inspection Type(Fill one) <br /> Site Suffix: J �U b ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: S (\ (0 al L't1 n CQunk o CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ((w)(-0 c. <br /> Es�Ao <br /> Physical Address <br /> 3aa E . Vje�MLO ra— Ave _ 1 <br /> a n�G1 �33t� Inspection Date <br /> G(� C <br /> -1 Time In Time Out <br /> l 111 <br /> BusinessC�(ep, ��M+ `I W Title5 � f� 0 AM 0 AM <br /> � (9 c <br /> � I 1 J O PM � O � PM <br /> Q�C 5,(/lQ n <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I 4 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active If Passenger ® Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> D Q Inactive * Truck <br /> Longitude - Q 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 C,p41at(1_w / <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMEN(((T STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 - --- Q Notice Of Violation Q Extension <br /> § <br /> PRC 42951 Waste Tire Hauler Registration and Transport of Tires <br /> 0 o PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q 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 <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> Q o 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q o 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q o 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments �c)1/t�f� v \fc• (1S f� U� 7 a (��� 111�\/v� <br /> �10 Ui OVAk nnS OJ 00 -cnS A tbAtc-rn' <br /> Inspection FormIncluded: <br /> a l io - 09 V-3 1'7 Zl <br /> Comments Included: - --- — - - - -_ ---�--- - - <br /> Busmess Rep's Signature Phone Number _Insp or's Signature _ Phone Number <br /> -- ---- — - 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: , EXAM P L 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: E © ■ <br />