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Waste Tire !Aey & Inspection Repot, Inspection Report Number <br /> Cal6eeycle State of CalRecycle <br /> 181nia I 1 - 1226312 <br /> Caycling le 181(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- LI _ ! 1 Inspection Type(Fill one) <br /> Site Suffix: _1 u J * Routine Q Re-inspection Q Referral Q Observation <br /> Local �1�- 1 / If Referral,choose referral type(Fill one) <br /> Identifier. Sa , J d a t 1' r� t�{�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Is (!-(A�-c- A I II <br /> Physical Address - V l � Q <br /> � Inspection <br /> v���� � �� Date <br /> V lJ/ Time In Time Out <br /> Business Rep (Title <br /> 1 � O AM � u O AM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> Q ® Active 0 Passenger 41 Generator Q Outdoor <br /> O <br /> GPS Latitude Q Closed Q Altered <br /> Q Hauler 0 Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 0 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 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 /> 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 <br /> Inspection Form Included: t /f.ti /1 t��lY —3 <br /> `4 <br /> 1 <br /> 31 17p <br /> Comments Included: ® o <br /> Busir4ss Reps Signature Phone Number Ins toy's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A V E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink 4y: <br />