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02 Waste Tire SL- ✓ey & Inspection Report <br />State of California <br />CalRecycle <br />CalRecycle ii3l (Rev. y (Cal Survey Form - Page 1 <br />Dept, of Resources Recycling and Recovery (CalRecycle) <br />Part A - Survey <br />Inspection Report Number <br />I1 - 1242228 <br />BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPID - � -7 O <br />Site Suffix: <br />Inspection Type (Fill one) <br />0 Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />QCHP QCalRecYcle 0 Complaint QEducational Visit QOther <br />Local <br />Identifier: m \ 1 +. <br />V <br />Inspected By Inspector <br />Business or Facility Name f <br />tnwke-s - <br />Physical Address <br />Inspection Date c) ? / 2 -1 / <br />YC <br />Time In Time Out <br />Business Rep Title <br />[ 9 AM t J 16 AM <br />1 0 • S J �,. <br />°E avec Mttr� SNa. <br />O PM Q PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />cc�n cec o <br />Tire Count (Whole/PTE) <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />* Active <br />Q Closed <br />Q Passenger <br />Q Altered <br />0 Generator <br />Q Outdor <br />N <br />GPS Latitude <br />Q Hauler <br />of <br />Q Indoor <br />Q Inactive <br />Q Truck <br />O <br />Longitude - <br />Q Planned <br />41 OTR <br />Q End -Use <br />Q Container <br />Business Type (Fill all that apply) Z <br />Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader 0 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 0 Other &h &%SN;N' 6A <br />Part <br />B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />V <br />F A <br />HAULING AND MANIFEST REQUIREMENTS <br />Q Notice Of Violation Q Extension <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline <br />PRC § 42956 - Registration/Decal in Vehicle <br />QQ <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date FTI / m / m <br />O <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />(Required for NOV or EX7) <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q Referred / CalRecycle Enforcement <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />In Compliance - No Violations <br />Q <br />1 Q <br />1 Other: § <br />Comments��,�; <br />oW WC►9 r� <br />- <br />Inspection Form Included. Q <br />JB,ss <br />Comments Included. <br />Rep's Signature Phone Number Inspec or's Signature Phone Number <br />V 62081 <br />INSTRUCTIONS ON BACK Correct: Incorrect:] �j EXAMPLE 1112 3 <br />White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA <br />�h <br />