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Waste Tire SL. ✓ey & Inspection Repor► Inspection Report Number <br /> CalRecycle State of California I 1 - 1255713 <br /> CalRecycle <br /> 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- � 5C) � � � � � Inspection Type(Fill one) <br /> Site Suffix: !� I* Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Gag ��� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility <br /> Name Inspected By Inspector <br /> Physical Address <br /> �� ��n �� Inspection Date <br /> CTime In Time Out <br /> Business Rep Title U AM 9 ^` 0 AM <br /> 2- -1 � � PM � V 0 PM <br /> 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 /> •Active Q Passenger 0 Generator Q Outdoor <br /> GPS Latitude 0 Closed Q Altered <br /> Q Hauler 40 Indoor <br /> O Q Inactive ' 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 40 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 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 EXE <br /> ti <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years n <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 e1,11,, <br /> rl J S \ N <br /> o ✓IS r S wCe�'✓� <br /> Inspection Form Included: �A <br /> Comments Included: d -01040 77 `— 6%-R2Z <br /> usin s ure Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK rrect: Incorrect: x ��,{ EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />