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Waste Tire Sui vey & Inspection Report Inspection Report number ■ <br /> Cw Recycle State of California I 1 - 121017 7 <br /> CalRecgandR(Rev.y(Cal 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- � � � � � � � _ O I Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local l If Referral,choose referral type(Fill one) <br /> Identifier: J d q V�� Cd v V 0 CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ! r Inspected By Inspector <br /> Physical Address �V�W 99 1 01 M�T'T V <br /> 2-2-t 0 • co'c CJ's`-O 1 0 V e - - - <br /> Inspection Date `� <br /> SVoc� �o C� 9521 S / <br /> Time In Time Out <br /> Business Rep Title I 1 I O AM O AM <br /> C\4_ GG-C—�Y\ T{.Cy'�' O PM A PM <br /> — C` 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 /> ®Active 0 Passenger * Generator 0 Outdoor <br /> 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 0 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 /> PRC§42956-Registration/Decal in Vehicle <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 /> 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 /> Comments <br /> CNINVOZ 0 �a S <br /> 0�� �— <br /> Inspection Form Included: 101643 6?06 <br /> Comments Included: 1 <br /> Business Rep's Signature Phone Number Insp ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: NJ IEIXIAIMIPILIEI 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />