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Waste Tire SL%ey & Inspection Reporpinspection Report Number <br /> State of California <br /> CalRecycle 11 - 1245077 <br /> CalRecycle 18t(Rev. (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 I A � � � � � O Inspection Type(Fill one) <br /> Site Suffix: "� a Routine Q Re-inspection Q Referral Q Observation <br /> Local f^ If Referral,choose referral type(Fill one) <br /> Identifier: 1 O v;� COV Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v Inspected By Inspector <br /> hV\.`��%h� � C �� ` vPhysicddress C) ` U <br /> �33b Inspection Date D <br /> Time In ` Time Out f <br /> Business Rep Title 0 AM O AM <br /> `,, M, S O PM I O •PM <br /> 'b•` C a ' " n'' - �` 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 /> Active Q Passenger 0 Generator IS Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler a Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 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 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 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 / 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) 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 /> 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 <br /> Q Q Other:§ <br /> Comments ` P ` _ Ac,-*- yvS v, <br /> Inspection Form Included: Q <br /> 70q_qZ_3 8L <br /> Comments Included: 40 <br /> Busi ss Rep's Signature Phone Number Inspect s Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect: I E X A M P L E 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />