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® Waste Tire Su. �1y & Inspection Report spection Report Number <br /> CalRecycle State of cleCalifornia8y pqs 11 1226658 <br /> CalRecycledReco Recovery <br /> o) Survey Form ® ■ age <br /> Dept.of Resources Recycling and Recovery(CalRecycle) � �r BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 1 Cp ` 0 1 Q Routine Is Re-inspection Q Referral Q Observation <br /> Local �� _1 If Referral,choose referral type(Fill one) <br /> Identifier: �(� J U �1 {1,1,A Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> `�t f e-S "\ �C5 S - a - C� 1 Eseo <br /> Physical Address <br /> a6 R,� Un eve 1 <br /> r q 1s Inspection Date <br /> LIG L[�, ` Time In Time Out 111 <br /> AM <br /> Business Rep Title � AM <br /> r � 22 <br /> _t 1� 1 V o O PM 1 I J O Q PM <br /> I u.rlUl v;,- Sal e: Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) v S Active S Passenger ® Generator Q Outdoor <br /> o Q Closed Q Altered <br /> GPS Latitude ® Hauler ® 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) <br /> ® Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> New Tire Dealer Q Auto Repair <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station 0 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 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 /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m m N <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXT N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> ntf <br /> E <br /> Enforcement <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle2 <br /> Lu <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 /> 1010 Other: <br /> Comments o(1 1�IZ���I , �'i fls� ll -eLae— <br /> `1 �stWW Oyt� V ,��a��UnS l )/�Ve• ��1� �C�I (c Ci�eC� <br /> Inspection Form Included4Biness <br /> �� <br /> Comments Included - JJ-f �a ep's Signature Phone Number Inspe is Signature Phone Number <br /> • NZ 1 2 3 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ( E :{ A M L E <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA <br />