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Waste Tire Sup vey & Inspection Report -Inspection Report Number <br /> Cal Rec cle State of California <br /> Y CalRecycle 1aj(Rev.10/10) 1 1230228 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- _7 Inspection Type(Fill one) <br /> Site Suffix: + (. / 2 1 ' , Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �GGS� �Z�(� V� _ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1� Inspected By Inspector <br /> Physical Addresj 2 <br /> C1,\- 953-77 1 Inspection Date Z <br /> Time In Time Out <br /> Business Rep Title / ` e <br /> �..Q 0 0 PM / 40 PM <br /> V` ) <br /> IOU <br /> V��� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) ' 1 Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J 1 Active 0 Passenger Generator JW Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — Q Planned is 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 40 Collection Q Crumb Rubber <br /> Q Service Station 0 Hauler Q Agriculture Q 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 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / 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 EX7) <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 /> W <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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:§ <br /> Comments I <br /> vzz <br /> Inspection Form Included: Q Z�. 4 /� �[� —32 <br /> Comments Included: `�� pU GO <br /> Business Rep's i inature Phone Number Inspect 's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X 9 EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />