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Waste Tire Su. ,✓ey & Inspection Report Inspection Report Number <br /> CalRecycle State of California( 11 - 1230433 <br /> CalRecycle 187(Rev.y(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- 1 2 \ _ 1 Inspection Type(Fill one) <br /> Site Suffix: l 1 If Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S0.Y1 Q CHP Q CalRecycle0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> DT <br /> r�. Q Foos q _ 1 M v <br /> Physical Address c> 4 ' <br /> ` Inspection Date <br /> Time In Time Out <br /> Business Rep Title +AM 1 �(� M'AM <br /> ` o 0 PM 0 !3 0 PM <br /> - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 9 91 0 Active Q Passenger 10 Generator 10 Outdoor 7 , <br /> GPS Latitude O Q Closed Q Altered Q Hauler 0 Indoor 2 <br /> O Q Inactive Truck <br /> Longitude - Q Planned 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 O 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 S 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 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 /> 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 <br /> g <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 0@ In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments vv-p_ wast- l Ycoec_�m--ern /*).L9 a U\ `TIniS all <br /> Inspection Form Included: � [)'� S? <br /> Comments Included: <br /> Hess Re 's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA <br />