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rti Inspection, Report Number <br /> Waste Tire S ay & Inspection Repo <br /> CalRecycle State of California I 1 1245338 <br /> CalRecycle cover (Ca[ Survey Form - Page It <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 7 � ,,., Inspection Type(Fill one) <br /> Z <br /> Site Suffix: _ (J I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Gt 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> vYC �Physical Add�ss S <br /> C 4 Inspection Date / / f <br /> Time In Time Out <br /> Business Re Title 0 AM AM <br /> Rep i o z, 9 QPM � a l QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count hoe/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ( <br /> L ® Active e Passenger ® Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive e Truck <br /> Longitude — 0 Planned e OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other IUW SLYvi-lu <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 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> 0 0 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 EX7 n <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> f <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance No Violations o <br /> 0 1 Q Other:§ <br /> Comments ` <br /> i <br /> �C- <br /> Inspection Form Included: 0 <br /> 40 9-2to 7 <br /> Comments Included. <br /> Effeffigss Rep atu Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK FCorrect-0 Incorrect: X a� q1jEjXjAjMjPjLjEj1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />