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Waste Tire S ley & Inspection Repot -Inspection Report Number <br /> CalRecycle State of California 11 - 1226282 <br /> Ccyclin and <br /> cover (Cal 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: S q , ® Routine Q Re-inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: svvn -, w O CHP O CalRecycle Q Complaint O Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 3 0 1 h38ioe-n s,4j <br /> cA cis-7c)4,i Inspection Date <br /> Time In Time Out <br /> Business Rep Title �� � PM �, � S � � PM <br /> © I <br /> �1iSci ��y'1y�G�JCX�'G1' �-�1'Y►ir►•�fCi S �'. - — --- <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active • Passenger i Generator Q Outdoor <br /> GpS o Latitude Q Closed Q. Altered <br /> _ <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) /N/A <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 /> — -- ---- ----- ------ Q Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 Q PRC§42956-Registration/Decal in Vehicle / m <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / MN <br /> O 0 14 CCR§18459.1 Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXTj N <br /> 0 O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 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 /> O ® 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators in Compliance-No Violations � <br /> Q Other:§ <br /> Comments <br /> 14A r <br /> Inspection Form Included: O <br /> Comments Included: ® ) <br /> � Busi s Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ' X A L 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop .L <br />