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Waste Tire Sup vey & Inspection Repon Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1177637 <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- Inspection Type(Fill one) <br /> Site Suffix: <br /> � J � 5 t 10 Routine Q Re-inspection Q Referral Q Observation <br /> Local Q If Referral,choose referral type(Fill one) <br /> Identifier: ��� E� ,�tv� E !L+ `� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ll Inspected By Inspector <br /> z o t <br /> Physical Address AN 6 L)) yj <br /> ,� �+,�L-A Inspection Date 1 / � -'7 / <br /> CA_i�.+T_ 1 f <br /> C(�c DQ& r l <br /> Time In Time Out <br /> Business Rep Title p (0 AM 1 P ® AM <br /> �if".e�. 1'?�H tp�+/ .,�,�✓+ 1 1 © O PM ( �t 0 PM <br /> S' iI Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) t (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 6 ® Active Q Passenger ® Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive • 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 0 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 /> 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) <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 <br /> In Compliance-No Violations o <br /> Q Q Other:§ <br /> - - <br /> Comments <br /> 47 <br /> Inspection Form Included: 0 <br /> Comments Included: � <br /> B sine Reps i at a Phone Number I plec ig ture Phone Number <br /> INSTRUCTIONS BACK I Correct: Incorrect: NA � A L 1112131 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop •L <br />