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Waste Tire Arvey & Ins ection Re ort Inspection Report Number <br /> CalRecycle Inspection <br /> P - 1255927 <br /> State of California I 1 <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- Inspection Type(Fill one) <br /> � � � <br /> Site Suffix: j U , 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local .-- If Referral,choose referral type(Fill one) <br /> Identifier: <br /> sm.,, Jdc,.c���Yl C(it.9 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> T*T ( Yve: Z12C.. . i <br /> Physical Address ( 7591 - v ` }iV Dc)v�L ►�(/{-i2 I-w <br /> ®� Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AM (0 AM <br /> �' 6 PM �' 40 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Coun (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active Q Passenger ® Generator ®Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Is 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 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 <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 n <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 /> 2 <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments I)„ i.L7 �� 11�c.2ir'�- � Gk �/, •_ �.� L��� � �, <br /> vC 0,r C �var cr2a �vc.t�-� <br /> Inspection Form Included: Q <br /> Comments Included: 0 <br /> Bu ' ss Rep's Signa Phone Number Ins'pe4.1 Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ZX �jEjXjAjMjPjLjEj12 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />