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Waste Tire SuIrvey & Inspection Report Inspection Report Number <br /> te aliforia <br /> CalRecycle CaalReofCe181n(Rev.10H0) 11 - 1196646 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A-Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 3 �! —1 `(� ® Routine Q Re-inspection Q Referral Q Observation <br /> Local \ If Referral,choose referral type(Fill one) <br /> Identifier. e." JFxb�/I"` �� O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Faci_lit-y NNaame}� Inspected By Inspector <br /> Physical Address j f{—j`Z�>✓L� <br /> czs—� A r� - <br /> 1 Inspection DateCA <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 2 ' O PM ® PM <br /> 0 <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 /> r ` Z." <br /> / <br /> L/ 0 Active Q Passenger ® Generator ®Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude Q Hauler O Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned ® OTJJ� 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 n <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other ,r4 ,� <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 0 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 O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> LU <br /> W <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> O 0 Other: <br /> Comments <br /> -- <br /> Inspection Form Included: <br /> Comments Included: (011 <br /> i9ssRep's Sig tura Phone Number pe or' Ign re Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: 7X74�7V] E X A 111213620811 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co ® ■ <br />