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03' Waste Tire Survey& Inspection Report-__Inspection Report Number_ <br /> CalRecycle State of Californ(Rev. <br /> a T 1 1 2 4 2 1 ®2 1 <br /> CalRecycle lndh Revery(Cal Survey Form - Page 1 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey -- - — <br /> — - <br /> Part A- SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details r + <br /> TPID- 1 Oj l ` _ ® t Inspection Type(Fill one) <br /> Site Suffix: b _'� 1 . Routine Q Re-inspection Q Referral Q Observation <br /> - I <br /> Local . i If Referral,choose referral type(Fill one) <br /> Identifier: 1L Q CHP Q CalRecycle Q Complaint Q Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Ass l M=06 1 <br /> Inspection Date / I / PO <br /> �--- Time In Time Out <br /> - LiP�'cxie <br /> O AM O AM <br /> Business Rep Title <br /> I d i , <br /> 10 �j �•PM 0 P <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 /> ' ' r 40 Active 0 Passenger 40 Generator 0 Outdoor <br /> O 0 Closed Q Altered <br /> GPs Latitude � Q Hauler 0 Indoor <br /> O Q 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 Q Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 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 /> Notice Of Violation 0 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 /> 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 Exf) 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 0 Referred/CalRecycle Enforcement <br /> 2 <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> —CSI`���r�ll►�-S X110- �- <br /> �2.Q �c,�v��r•e�l� <br /> � Inspection Form Included: 0 � � �/�`2�S. � ���`� <br /> Comments included: u ( 7 <br /> Business R '4 <br /> ep's ature Phone Number Inspe' or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X* rJ E X A M P L E 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />