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M 2 Waste Tire Su,Bey & Inspection Report Inspection Report Number ■ <br /> Cal Recycle State of California( I 1 - 1210398 <br /> CalRecycle 181(Rev.y He) 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 j"� I Inspection Type(Fill one) <br /> Site Suffix: ` _3 3 7 S v ` ® Routine Q Re-inspection Q Referral Q Observation <br /> Local � J If Referral,choose referral type(Fill one) <br /> Identifier: ��" J O0.1 v;n CO V V` 0 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name /// Inspected By Inspector <br /> Physical Address <br /> Inspection Date / ` / r 3 <br /> Time In Time Out <br /> Business Rep Title S 0 AM l 0 AM <br /> t'fey is PM -1 0 PM <br /> a� IAQ CNLz <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) (Fill all that apply) <br /> �6 ® Active Q Passenger 40 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler b 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 <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 <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 /> 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 /> US <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 /> Comments <br /> z jcS�Nma_ etc c>zi:�s -_e3k Cance-lrV\_ <br /> Inspection Form Included: Q SDI <br /> Comments Included: (, D 1-1 t3��2�� *� 2ocl— 1Ur�Lty0 -J? <br /> Z24 <br /> Bu ess Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct:* Incorrect: X *� EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />