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Oa Waste Tire Su. „ey & Inspection Report -,ispection Report Number ■ <br /> CalRecycle State of California I 1 - 1178003 <br /> Ccyclin and le 181 <br /> (Rev.Recovery <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 Type(Fill one) <br /> Site Suffix: 1 ! ® Routine Q Re-inspection Q Referral Q Observation <br /> Local (� _l� `` � > L If Referral,choose referral type(Fill one) <br /> Identifier: `xeo-4-t,!�/ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> - <br /> Physical Address �� 1 <br /> �1� �. �f1 G�')►ZrCr 13-�- <br /> CA <br /> Inspection Date -7 / O / 7 <br /> � � Time In Time Out <br /> Business Rep Title ® AM AM <br /> • Q PM O 5 O PM <br /> v�Cl✓ t — ��J Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) a (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 —� ® Active Passenger ® Generator ® Outdoor <br /> D Q Closed Q Altered <br /> ��� Latitude Q Hauler ® 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 /> 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 T yt n <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) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 o <br /> Q Q Other:§ <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: ® <br /> Business Rep's Sig ature Phone Number 4pe o s Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect: X �t NJ E X M P L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy L L" ■ <br />