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Waste Tire Su. Bey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1230261 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � - O � Inspection Type(Fill one) <br /> Site Suffix: `� J `-'1 -1 • Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �Q Yl aGa �3 i YN CG�3 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> CV'ew,,c�� <br /> Physical Address <br /> 1077 <br /> Inspection Date <br /> Time In Time Out <br /> Business`Rep Title 0 10 AM10 AM <br /> Y-�-1�e1 ��•h�Z (� 1 _ O PM o Q 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 /> •Active Q Passenger 0 Generator Q Outdoor <br /> PS Latitude <br /> O Q Closed Q Altered N I� <br /> G Q Hauler Q Indoor <br /> o Q Inactive 4@Truck <br /> Longitude - Q Planned Q OTR 0 End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 0 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> Q 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 EXE <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 0 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 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Q 1 QOther:§ l 1 <br /> Comments t y"C 30= dO <br /> Pe�S C@ ry-C.0 <br /> Inspection Form Included: Q / d l,�� <br /> Comments Included: 1406. �G �lr"—3Z <br /> Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:41 incorrect: � NJ EIXIAIMI P I L I El 111-2 3 62081 <br /> . White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />