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0I Waste Tire SL. iey & Inspection Report Inspection Report Number ■ <br /> Cal Recycle State of California 11 - 1210520 <br /> R <br /> CalRecycle (Rev.y(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- i t rl S _ m 1 Inspection Type(Fill one) <br /> Site Suffix: 1 v ® Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier. S^�� vf, C���1V� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> 0,0 <br /> Physical Address 3 V y ES'ju Q <br /> Inspection Date <br /> c Time In Time Out <br /> Business Rep TitleO APM f® AM <br /> N ID MINI Ah-OckntIZ, 1 � Q 0 PM <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 /> 0' r • Active Q Passenger 0 Generator 0 Outdoor <br /> O Q Closed Q Altered ,v <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 10Truck <br /> Longitude - Q Planned Q 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 1 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder • Other S c6i / <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 /> 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 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 O 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 Q Other:§ <br /> f+ 1,� <br /> Comments T(yr� 1 W� V W� - ��5 1 t�SdA <br /> ---- <br /> Inspection Form Included: O p� J <br /> Comments Included: ® "A09 920995- <br /> Business Rep' Signature Phone Number Inspec 's Signature one Number <br /> INSTRUCTIONS ON BACK Correct: incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />