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Waste Tire SL.. vey & Inspection Repor� Inspection Report Number <br /> CalRecycle State of California m 11 - 1230332 <br /> CalRecycle 191(Rove ry(Cal S rvey Fort l R - Page 1 - <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey <br /> Part A-Survey _ BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- I g 3 $ Inspection Type(Fill one) <br /> Site Suffix: I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SA(1ZdLl. VLA Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> E\ <br /> Physical Address <br /> dress <br /> Inspection Date <br /> 1�r1 Time In Time Out <br /> Business Rep Title0 AM� � �J/� d PM � O � O AM <br /> ��� ® PM <br /> �� vv.�ner <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> i _ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � l� <br /> Active • Passenger ® Generator 1* 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 /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 <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 N <br /> a <br /> 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 Q1 Other:§ <br /> Comments <br /> `1 Se-t�_ (�I)t'(�mcfl ��stc1 <br /> Inspection Form Included: QILO_4�� <br /> ( [ r <br /> �Comments Included: <br /> _ Business Rep's Signature 063ne Number Inspe is Signatur110fione Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: JEJXJAJM 1 Z 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: ® 0 <br />