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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1196624 <br /> Ccyclin and R(Rev.y(CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> r 'A-Survey BLUE OR BLACK INK PEN <br /> gess Profile Inspection Details <br /> I r-ID- Inspection Type(Fill one) <br /> ( <br /> Site Suffix: l -7 (o Jc— g L © l (10 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S e-•V" 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> �O e.\ C)[�C zJ <br /> Physical Ad red"ss - ( Q t �-t� �- Q L-LI-1 <br /> bei ►°� . <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title I O AM O AM <br /> ` <br /> �1�� ��� �eUC%✓1/i � � ® PM ® 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 Active • Passenger 0 Generator 0 Outdoor <br /> GPS Latitude O ® Closed 0 Altered O Hauler Q Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 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 � 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 /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 EXn N <br /> a <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 /> 2 <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 0 In Compliance-No Violations o <br /> Q O Other:§ <br /> Comments <br /> J�l�'{�7w.1 ►Lat'Y)'Lo MSr�A�\, ��Lo t/�bicti.�bYtS �(1`0f[�) �J1���/�✓ � o'�'ac pZ..t1dyL ,,, <br /> ON� � �jk o r� '�I/Is� ��� ���✓?sJ3 ,� �. !L'rJ 6 CJC✓[� _:�!►'J��d1-n.a ©(�c� <br /> ok ctjewlc -fiyas <br /> -b ✓zr.1.��3 •J ���w�3c� fie- G�tc,v�- Ge-o *t-o_ <br /> spection Form Included: 0 <br /> Comments Included: Q It <br /> vkV °Zd�"rG 8"t6 <br /> Business Rep's Signatu Phone Number Ins ct 's gna re Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK I Correct:0 Incorrect: jEjXjAMjP KJEJ 1112131 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA © ■ <br />