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® spection Report Number <br /> � Waste Tire Su. _y & Inspection Report � <br /> Cal Recycle State of California 11 - 1176627 <br /> R ry <br /> CalRecycle (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- Inspection Type(Fill one) <br /> -7 <br /> Site Suffix: 1- `'� l 3 -T- U f ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: u N Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Nam <br /> Inspected By Inspector <br /> Physical Address J - 0 / /1�ruy. ►✓CSC ' ' <br /> / c Inspection Date <br /> Time In Time Out <br /> Business Rep Title _ 0 AM 0 AM <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 /> ' 0 Q Active Q Passenger Q Generator Q Outdoor <br /> O ® Closed Q Altered <br /> CaP$ Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) - — - _ — /V/1�} /v N <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 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 /> / <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 EXT) n <br /> 3 <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <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 <br /> Q Q1 Other:§ <br /> Comments <br /> V -vi-w . nC1r44rne_— AS riCf Edd -- ��-- <br /> � <br /> Inspection Form Included: Q <br /> Comments Included: ® - `:77> � �Ob <br /> Zoe q&15 <br /> Business Rep's Signature Phone Number Inspecto ' Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: incorrect: ­1 71P l _ E X A M P L 11213 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink py: <br />