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Waste Tire S►,.. #jey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California( I 1 - 1196314 <br /> CalRecycle (Rev.Recovery <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: 0 $ 0 � ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local S- <br /> �U� ��V� If Referral,choose referral type(Fill one) <br /> Identifier: - (q�� k, 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name I_ Inspected By Inspector <br /> SOIL ,tx .nom L C>_Wj'L A CZtU I�'l.rG Y1G1 n Lam' 1 <br /> Physical AddreWsLCA <br /> Inspection Date 1 <br /> R�`�G,� Time In Time Out / <br /> Business Rep Title _ ®AM1 / ®AM <br /> �r� QPM I l � � QPM <br /> �" "�h y � ��' , Operational Status Tire Type Business Role Storage Type <br /> tFill one only) Fill all that apply) FIII all that apply) FIII all that apply) <br /> Tire Count(Whole/PTE) / ( ( pp y) ( pp y) ( pp y) <br /> / d 0 Active ® Passenger ® Generator I* Outdoor <br /> 0 Closed ®Altered <br /> GPS Latitude ® Hauler 0 Indoor <br /> O 0 Inactive Truck <br /> Longitude - 0 Planned OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet ® 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 0 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 0 Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 EXT) n <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <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 0 Other:§ <br /> Comments <br /> J <br /> Inspection Form Included: 0 <br /> Comments Included: ® / `'?ff1 �6�l6 Z._ <br /> uslness Rep's Signat re one Number s ct nature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorre E A I E 1 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: EA �� ■ <br />