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Waste Tire Sup vey & Inspection Report '`Inspection Report Number <br /> CalRecycle State of California 11 - 1177628 <br /> Ccyclin and le 181 <br /> 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: , �j �j 8 �i ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. �a� ��� Lv�V��'J Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business orFacility Name (� (( Inspected By Inspector <br /> t <br /> �1 CC + t r�7✓�t�f-Ci l S - ;n <br /> Physical Address <br /> Inspection Date <br /> Lam,i ��1 Cl Sq2 O <br /> Time In Time Out <br /> Business Rep Title 0 AM ^� 0 AM <br /> l Z ' 0 ® 0 PM 02 ' 0 PM <br /> C' rllcxvlZk ✓irc-.i�rvwl <br /> - Operational Status Tire Type Business Role Storage type <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> JS Active Q Passenger le Generator 419 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned ® OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <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 ® Others <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 � 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) 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 /> 2E <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q 0 Other:§ <br /> z <br /> Comments <br /> J ,c <br /> C/ <br /> Inspection Form Included: Q <br /> Comments Included: ® �!G 7� �b �LS?� <br /> 151 siness Rep's Signature Phone Number <br /> tl �, Phone Number <br /> - INSTRUCTIONS ON BACK Correct: Incorrect: KA V E X L 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cot <br />