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® Waste Tire Su. frey & Inspection Report Inspection Report Number <br /> CalRecycle State of California1R I 1 - 1196410 <br /> CalRecycle Y81(Rev.y(CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK Part A-SurveyK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 (0 S 3 1 O _ O Inspection Type(Fitt one) <br /> Site Suffix: Routine Q Re-inspection Q Referral Q Observation <br /> Locali� t r If Referral,choose referral type(Fill one) <br /> Identifier: S(�(� � ^ `(7M Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address 3 0 <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> ® PM I � � to PM <br /> 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 ® Generator ! Outdoor <br /> O Q Closed Q Altered <br /> ��� Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned 40 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) FU..V V <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 I bA-Ll4k <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 a <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 o <br /> Q 1 Q 1 Other:§ <br /> z <br /> Comments W w 1 f` 79ex" 10't on Y N <br /> Inspection Form Included: Q <br /> Comments Included: Sgntureusiness Rep's ignature Phone Number Insp iavi ly ll <br /> Phone Number <br /> INSTRUCTIONS ON BACK Correct:40 Incorrect: E X A M L El 1112131 <br /> 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pin 0 <br />