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i 12 8 4 05-0:0,:2- <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of CalifornialR 1 I 1 - 117 6 7 9 4 <br /> CBiRengandR(Rea.,°,t°, Survey Form - Page 1 J <br /> Dept of Resources Recycling and Reeovory(CalRecycle) I <br /> Part A- Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> Site SuTPID- Rl <br /> O Inspection Type(Fill one) <br /> ffix: [ 1 1N <br /> ® Routine Q Re-inspection Q Referral Q Observation <br /> Local t - It Referral,choose referral type(Fill one) <br /> Identifier. Sqn J q Cbl A f Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` <br /> Inspected By Inspector <br /> Physical Address <br /> Street <br /> `� �-tkun <br /> Zl� Inspection Date <br /> citLy -D State ZIP Code I Time In Time Out <br /> Business Rep Title I I S 5 Q PM � � � � 0 PM <br /> Y I Operational Status Tire Type Business Role Storage Type <br /> i I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> _T] N (�) <br /> Latitude m ® Closed Q Altered r "'1A NJ�� <br /> GPS Q Hauler Q 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 h <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I <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 /> Q Q 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 EXn n <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 f <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance No Violations o <br /> O Q Other:§ — -- --- ------ - - — - - __ J - <br /> Comments <br /> 1 <br /> 1 V 0Iw�_i_v11S—� <br /> Inspection Form Included: Q <br /> Comments Included: ® -- --— - -�=�����✓"`-�b <br /> Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correc Incorrect: ' d E X A M P L E 1 2 3 62081 <br /> White Copy:Ya Rec Yellow Copy:Operator Pink Copy:LEA ® ■ <br />