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Waste Tire Sukey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 11 - 1242426 <br /> Caycling le 181(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- � Inspection Type(Fill one) <br /> Site Suffix: 1 I* Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �v� O CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> 1�\ cam <br /> Physical Address <br /> Inspection Date O 7 <br /> Time In Time Out <br /> Business Rep Title t ` (D AM 0 AM <br /> b 1 1 d * PM O 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 /> r ' 0 Active O Passenger 0 Generator 0 Outdoor93 <br /> O 0 Closed O Altered <br /> GPS Latitude 0 Hauler 0 Indoor 19 <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned Q OTR 0 End-Use Q Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 9 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> Q 0 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 EX7) N <br /> O O 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 0 Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators !In Compliance-No Violations <br /> O O Other:§ <br /> Comments <br /> C'C .r rLS �c Ee�nCe�� <br /> Inspection Form Included: Q <br /> Comments Included: Jac <br /> B <br /> usiness Rep's Signature hone Number Inspe tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 62081 <br /> zX W E X A M P L E 1 2 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />