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Waste Tire S..r vey & Inspection Repot _ Inspection Report Number <br /> CalRecycle State of California ) T l _ 117645C! <br /> _ 1 7 � /I. [,, (1 <br /> CalRecycle le t8l(Rev.y(Ca Survey Form - Page 1 1 �1 (-� 1 f,., <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: I� 5 6 l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local U `�� If Referral,choose referral type(Fill one) <br /> Identifier: �(` i1 C1h. Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> P ; L Concxre� 3 - <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep TitleO AM .I O AM <br /> ' 4wPM S i®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) (FII all that apply) <br /> a 0 Active Q Passenger 0 Generator • Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned OTR Q End-Use ! 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 ./ r <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other CenGi-e_�i ti'LcttI ✓1CcL�c�y f�- <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 Q Q Notice Of Violation Q Extension <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 /> 0 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 N <br /> N <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 O Other:§ __-- <br /> Comments <br /> N <br /> Inspection Form Included: <br /> 03�-1� <br /> Comments Included: <br /> Business Rep's Signature Phone Number *Cop <br /> Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: M 4& CJ 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator © 0 <br />