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Waste Tire Sill,.. Bey & Inspection Repori.. inspection Report Number <br /> CalRecycle State of California( 11 - 1210 412 <br /> Ccyclin andle R(Rev.y(CalRecycle) Survey <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- © Inspection Type(Fill one) <br /> Site Suffix: t "� `� III& Routine Q Re-inspection Q Referral Q Observation <br /> Local � I If Referral,choose referral type(Fill one) <br /> Identifier. Son_J_ <br /> LArlQ CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> � ;ner � <br /> Physical Addres <br /> 0dicxJo s4_ <br /> �� c 1 ESC,UTTo <br /> Inspection Date <br /> �-ftnc� (,gree CH CL5a3) <br /> Time In S Time Out (� <br /> , Business Rep Title 0 AM 0 AM <br /> pro(�,wcJv Sy�Ur�, � � e PM � � `� ® PM <br /> Ij Mac {, qS 1�- - <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (FII all that apply) (Fill all that apply) <br /> 1 <br /> ' ® Active Q Passenger 0 Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned ® OTR Q 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 r <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other «ea PJ�k;pal} liS,1IW <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 <br /> 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 M / m / Ffl <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements DateQ 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 o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O 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 (0 In Compliance-No Violations o <br /> Q Q1 Other:§ <br /> p /'- 11 <br /> Comments _`f �, lel - -1-f1S t. t�On 0 is <br /> V <br /> L) y;CA�i(>� b T ut f 0' (,usUjn. <br /> Inspection Form Included: 0 � 1 OG <br /> Comments Included: ® l yC"— <br /> Business Rep' ignature Phone Number InsN or's Signature Phone Numbdr, <br /> � <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: � E X A M P L1 1112131 <br /> 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: ® 0 <br />