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02 Waste Tire SL. ,✓ey & Inspection Report inspection Report Number <br /> CalRecycle State of California 11 - 1196525 <br /> CalRecycle lndRec very(v. 10) 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 � � ! � - � � Inspection Type(Fill one) <br /> Site Suffix: b 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �.� If Referral,choose referral type(Fill one) <br /> Identifier: J d� V Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> v :r.S. 1_ '� 9 - 1Q <br /> ` <br /> Physical Address <br /> 2 �cecx <br /> Inspection Date q / t 3 / 1 3 <br /> Time In Time Out <br /> Business Rep TIjTitle sU' -r t 2 0 AM 0 AM <br /> 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whol2 -7/PT (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' ® Active 0 Passenger 0 Generator i Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> I* New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 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 <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 /> 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 CalRecycleIt <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (ReqIn <br /> uired for NOV or EXTJ <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> N <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 0 In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments ©yf\ <br /> Inspection Form Included: Q <br /> Zbq'ry��-32g <br /> Comments Included: <br /> Business Rep's Signature Phone Number lnspe tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A M P L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />