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02 Waste Tire Su. Bey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1230215 <br /> CalRecycle cover (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- 1 1 { - 0 � Inspection Type(Fill one) <br /> Site Suffix: V 411 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: aq/ '`'1/��v,,^ Czar Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name " �`77 Inspected By Inspector <br /> 0.0y - <br /> Physical Address d 1 T <br /> v <br /> \ 1 Cil Inspection Date I / I 1 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 PM I O PM <br /> *Toyer (`- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all rat appy) iFe all that apply) (Fill all that apply) <br /> 0 Active Q Paemnger 0 Generator Q Outdoor <br /> GPS Latitude O Q Closed Q AMmwa ;_; Hauler 0 Indoor <br /> o Q Inactive 0 ?r" <br /> Longitude - Q Planned Q C-4 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 Des+-&-Tw Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubb& <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 ENFOAGEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Noelcs Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> l7 <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Comphwme Deadline <br /> 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 EXE 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 /> 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 /> Commentst (y-IrZ� nh lS a4 � <br /> Inspection Form Included: Q 0000 <br /> Comments Included: ��� <br /> Business Rep's Signature Phone Number Inspecto 's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:40 Incorrect: X JJ � jE X A M P E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L ® ■ <br />