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Waste Tire S ey & Inspection Report - Inspection Report Number ■ <br /> cle State of California <br /> CalRec — <br /> Y CalRecycle 781(Rev. (Cal 1229979 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 I1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 I 2 9 I Inspection Type(Fill one) <br /> Site Suffix: , Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Say. �O ; ��V r Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Nam1e` ` V Inspected By Inspector <br /> S k o G�kll vm �to�`G`n 0- {�116}\yv�k � 3 I - o 1 MA T T ki <br /> Physical Address <br /> '399)2 A3. W�tVcoK V_c ,- <br /> S�ro at �� �� e15-t15 <br /> �21� Inspection Date <br /> L Time In Time Out <br /> Business Rep Title O AM J O AM <br /> \Y` a • PM 'Y ® PM <br /> s � a <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) Z 2 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active 9 Passenger 40 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer &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 Q 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 /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 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 /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q Q 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 \ '- <br /> b v �h 2C o in Xo✓1.r2 O)A <br /> r <br /> Inspection Form Included: y'j�b Gt <br /> � c 0 <br /> -62 <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspect is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: IEIXIAIMIPILIEI 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © 0 <br />