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Waste Tire SLRey & Inspection Report Inspection Report Number <br /> CalRecycle State c California 11 - 1245237 <br /> Ccyclin and R(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- � nl � t� - � I Inspection Type(Fill one) <br /> Q � <br /> Site Suffix: I "1 18 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: TOM C Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V <br /> Inspected By Inspector <br /> Physical Address <br /> �Z77d Cj , ��0.C�Rr • <br /> Inspection Date <br /> �f1 Time In Time Out <br /> Business Rep Title 1 O AM /''� 0 AM <br /> IP l I L Q PM Z • v 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 /> '760 Active Q Passenger 9 Generator I*Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 40 Indoor <br /> O Q Inactive #Truck <br /> Longitude - Q Planned Q OTR Q End-Use 4P Container <br /> Business Type(Fill all that apply) <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 /> 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 M / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle 5 <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 o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <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 4P In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments_ d h 0 S <br /> —if cs�n9 I^ce1'✓1 <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business R 's Siguture Phone Number InsplIll bgriature Phone Number <br /> INSTRUCTIONS ON BACK Co ect: Incorrect: EXAM' L 1 2 3 62081 <br /> ■ White C py:CalRecycle Yellow Copy:Operator Pink Co L <br />