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Waste Tire Sb. iey & Inspection Report inspection Report Number ■ <br /> State of California <br /> CalRecyclecalRecle 11 - 1210404 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 5 3 r S V ( ® Routine Q Re-inspection Q Referral Q Observation <br /> Local /t If Referral,choose referral type(Fill one) <br /> Identifier: S"1) �o��IA-,% n Ctrut� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> 1 Inspected By Inspector <br /> D oe, �(� It -ff u j r 3 q _ I <br /> Physical Address I Q <br /> c Inspection Date I 1 3 ' 3 <br /> (�( C'CII �533� Time In Time Out <br /> Business Rep/- f1Title nn /l ® AM ( I �j 0 ® AM <br /> 17 <br /> Joe 0 'l'1� Owne'- I vt U O PM t ! �/ Q PM <br /> S - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) r1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> d ® Active Q Passenger 0 Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 /> 0 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / IT] / 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 EXE <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ®In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> Comments �� 1 f �^_.1 Cui t N <br /> 41DAO tAA M, UU fl� - <br /> N (�lscaaS Of GU cel n- <br /> Inspection Form Included: <br /> Comments Included: 0 1 A <br /> usiness Rep's SiglAPhone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS f BACK QmTect:0 Incorrect: EXAM E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cq&� <br /> ® ■ <br />