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02 Waste Tire Su*ey & Inspection Repo Anspection Report Number <br /> State of California <br /> CalRecycle 11 - .12 2 9 9 8 3 <br /> CalRecycle l8{(Rev.y(CalRecycle) Survey <br /> 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- � `7 � I � � � - O � Inspection Type(Fill one) <br /> Site Suffix: • Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> �Y_' c V Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V <br /> Inspected By Inspector <br /> 15�'6 Cx_ Tcv�tit�r.� �rC. q - 1 O IT v <br /> Physical Address A <br /> Inspection Date o 3 S <br /> Time In `J Time Out <br /> Business Rep Title � Q�E� : AM � � � O AM� r _`� �{�t •�_ �� PM PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ") <br /> 0 Active Q Passenger 0 Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair . 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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q 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 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / 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 EX7) N <br /> v <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 /> 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 Q Other:§ <br /> Comments9. <br /> `v� W0..\ _ t L� c•�•� �1/�� OY` •��t S <br /> Inspection Form Included: It <br /> 4 �Q� <br /> Comments Included: w `� "`_t-32& <br /> �e <br /> Business Rep's Signature Phone Number Inspec or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � � 62081 <br /> EXAMPLE 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />