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Waste Tire Survey & Inspection Report Inspection Report Number <br /> cle State of California <br /> CalRecycle CalRecycle R ry(Rev. (Cal Survey Form - Rage 1 11 1226314 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 5 3 _ 0 � Inspection Type(Fill one) <br /> Site Suffix: 4j Routine Q Re-inspection Q Referral Q Observation <br /> Local q If Referral,choose referral type(Fill one) <br /> � <br /> Identifier: SAy-) J0 jA1'\ coU,�1Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 5Uper- ' o>vL ne�s a } <br /> Physical Address I 1 d I e� Cpb <br /> Inspection Date <br /> LuA�)�0P CA X5330 <br /> Time In Time Out <br /> Business Rep Title O 0 AM I I 0/l ® AM <br /> �( 11 ,_ Q PM V Q PM <br /> — -- -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) no (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger 0 Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 16 Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned 0 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 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 0 Other NeJfillI& -(.A1 UJAfC btM5<_ <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 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 0 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) N <br /> r <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 <br /> ®In Compliance -No Violations o <br /> Q 1 Q 1 Other:§ _ <br /> Comments t f ► ( z <br /> �u��� w�.Sk� 1r� 3n ��-,ca•___�,��e. rut �n� -�'o llr�-(,t�,n �, <br /> I-A <br /> Nola un-S. b1' a,(cc a-� if)Luff). -- <br /> Inspection Form Included: Q v <br /> Comments Included:® u <br /> Business Rep's Signature Phone Number nsp tor's Signature _hone Number <br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect: X E X A M P L E 111 <br /> 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />