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rr <br /> Waste Tire Sl.. ✓ey & Inspection Repononspection Report Number <br /> CalRecycDept.of le s RCalRecyclo 18.1ecycling anRld ifornia <br /> (overy(CalRecycle) Su n9 e Form - Page 1 11 - 1245265 <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- + � � � � � ` Inspection Type(Fill one) <br /> Site Suffix: I J 0 Routine Q Re-inspection Q Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: cc�'v Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name / Inspected B Inspector <br /> P Y P <br /> Physidal Address 3 ` ` v <br /> d� Inspection Date <br /> X524 Time In v Time Out <br /> Business Rep Title 'VO-OCN) 45 O 0 AM 1 O AM <br /> 40PM 2 ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) fl1J <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 9 • Active Q Passenger Generator Q 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 0 End-Use Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader 0 Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber �p <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 46 Other �ff� � /►ae'. Vt"` <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VI 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 <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <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 <br /> Q Q 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 /> Comments �1/vsP <br /> c <br /> Inspection Form �nc <br /> ncluded: Q � *Insp /tor'ls�Slgnature <br /> � /%'����W/ <br /> Comments luded: <br /> C! of! <br /> usine Rep's Signature Phone Number Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />