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Waste Tire Su, vey & Inspection Report Inspection Report Number <br /> Cal Recycle State of California( I 1 v 1229921 <br /> CalRecycle <br /> and.l(Rev.y(CalRecycle) Survey <br /> 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� � Inspection Type(Fill one) <br /> � � � _ Q � <br /> Site Suffix: & Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 5aj�­aC_ �A WA4 ` r.c . Q _ 1 1 <br /> Physical Address l AAA I 1 V <br /> I r� q3-';0 Inspection Date O ` � Z Z � � S <br /> V0-�fV� `-' \ � Time In Time Out <br /> Business Rep Title O AM C 0 AM <br /> �('� ` Z_ 9 5 a PM �, � J ®PM <br /> p�\ 1(j V cl -ZJe. Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) )2� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active • Passenger S Generator Q Outdoor <br /> 'KAGPS O Q Closed Q Altered Latitude Q Hauler Q Indoor <br /> O Q Inactive I* Truck <br /> Longitude - Q Planned • OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader 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 0 Other Ml3TOLF."�► <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 Q Q Notice Of Violation Q Extension <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 /> PRC§42956-Registration/Decal in Vehicle <br /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date[T] <br /> / m / m <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 EXT) <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 /> 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 In Compliance-No Violations o <br /> Q Q Other:§ 1 <br /> Comments TaNyNZ%!!R <br /> Inspection Form Included: Q <br /> Comments Included: 0 - <br /> Business Rep's Signature Phone Number Inspec 's Signature Pho�Numb�er <br /> INSTRUCTIONS ON BACK Correct: Incorrect: M "� q IIEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />