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y Waste Tire �aurvey & Inspection Rep(.. f Inspection Report Number <br /> CalRecycle State of Cal'dornia 11 - 1245132 <br /> CalRecycle Recovery <br /> survey Form m Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACKINK PEN <br /> Business Profile Inspection Details <br /> TPID- 'j � �7 ;l �� � _ � r Inspection Type(Fill one) <br /> Site Suffix: Il L C J I 1111 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S� ^)Oaq u l 1� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Bu iness or Facil'ty Name I 1 Inspected By Inspector <br /> C� VAC -e L <br /> Physi al Address , ' C� S/J/�W� ` 1✓ <br /> Inspection Date 1 <br /> Time In Time Out <br /> Business Rep ����qq Title /1 0 AM 7 AM <br /> 0111 !' UQ' /rte W� U OPM v' ®PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Countole/PTE) n Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �; L $ Active Q Passenger .Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GP� Latitude Q Hauler Q Indoor <br /> O Q Inactive &Truck <br /> Longitude - Q End Use Q Container <br /> Q Planned Q OTR <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 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 /> N <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 /> 2 <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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 , L� N <br /> GY <br /> Inspection Form Included: Q zo 't(� <br /> �/W' <br /> Comments Included: ® �• <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: JEjXjA1m. PjLjEj 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />