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Waste Tire S ✓ey & Inspection Repor Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1242394 <br /> CalRecycle cover (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- ' ` Inspection Type(Fill one) <br /> Site Suffix: 'A 01 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SO`h 5oaq V Co O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �ocCo.� �Ca.�c•s�,c� � Q, � _ A <br /> Physical Address rOL Oh —1 ` M J.A� <br /> , _ <br /> C " <br /> S �1� Inspection Date 3 I <br /> Time In Time Out <br /> Business Rep Title1 © AM Q AM <br /> Q PM PM <br /> ��e-V2.Y1 �IL �C� 1 � Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active O Passenger ! Generator Q Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive ® Truck <br /> Longitude — Q Planned O OTR O 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 <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 /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> O O Other:§ `— _ __ _ \ _ <br /> Com .Ov $3 \v�Spe CNC�Ca'rx <br /> Inspection Form Included: Q ll <br /> Comments Included: l 6 <br /> Business Rep's Signature Phone Number Inspe tot's Signature Phone Number <br /> 62081 <br /> [Correct,INSTRUCTIONS ON BACK �61n�correc�tX EXAMPLE 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />