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'2 Waste Tire SLiey & Inspection Reporonspection Report Number <br /> CalRecycle State of California <br /> (R 11 — 1229997 <br /> CalRecycle l8t(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- 1 7 5 a Inspection Type(Fill one) <br /> Site Suffix: I .Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �G Ga �Ty\ C'G k5 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> cOl1Inspected By Inspector <br /> Physical Address <br /> Inspection Date Q <br /> V-1 <br /> Time In Time Out <br /> Business Rep TitleWC <br /> P � t , � :AM � 1 � 0 AM <br /> "� PM I1GPMI—C_yn e.t' <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) J (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 10 Passenger 4P Generator Q Outdo r <br /> GPS Latitude - Q Closed Altered Q Hauler Q Indoor <br /> O Q Inactive + Truck <br /> Longitude — Q Planned OTR 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 • Collection Q Crumb Rubber <br /> Q Service Station 0 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 <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 /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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) N <br /> a <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 /> Lu <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:§ <br /> ` <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: •\mc -e <br /> Business Rep's Signature Phone Number AOW <br /> is Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct: Incorrect: M EXAMPLE 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />