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Waste Tire Survey & Inspection Report inspection Report Number <br /> CalRecy.Cle state of Califomia 11 - 1196402 <br /> CalRecycle 187(Rev.y(CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLU__E OR !SLACK INK_PEN <br /> Business Profile Inspection Details <br /> TPID- ` � � � � � � - � � Inspection Type(Fill one) <br /> Site Suffix: I Q Routine 9 Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sh(N J� u �,n �1 t 11 O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> G mum 3 - 1 es C0TT0 <br /> Physical Address <br /> C� <br /> Inspection Date <br /> �5�� Time In Time Out <br /> Business Rep Title Z 3 ` 0 AM ► ) O O 0 AM <br /> e PM <br /> J J 9 PM "� <br /> CL It� Dr � wn e� Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) r� O O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> #A Active 0 Passenger 40 Generator 0 Outdoor <br /> O Q Closed ® Altered <br /> GPS Latitude Q Hauler O Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned O OTR 0 End-Use O 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 0 Collection Q Crumb Rubber 'l <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® OtheroJus�C 7 <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 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m <br /> 0 O 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 EXT) h <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> W <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations o <br /> O O Other:§ <br /> 1 z <br /> Comments PScIv` mS I rr i 113` t N <br /> A C� ��7 �AA�) I �119l/t 1- <br /> aJr✓,A(h11S V3l611& "ESL), U►yL I1eRn <br /> Inspection Form Included: Q Z_ `2oq qq-(-9- <br /> Comments Included: 0 �G T <br /> Business Rep's Signature Phone Number Inspg'rl'STSgnature26 one Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: *��y EXAMPL 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L <br /> Lam-' <br />