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I <br /> Waste Tire SL. ,ey & Inspection Reportenspection Report Number <br /> State of California <br /> CalRecycle 11 - 1242433 <br /> CalRecycle R cover (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- 1 -7 � � A � 5 - O ` Inspection Type(Fill one) <br /> Site Suffix: C� 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: (kh �o�� v;V-\ � Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> M i S <br /> Physical Address <br /> ckInspection Date 07 / 02- <br /> y <br /> ���� Time In Time Out <br /> Business Rep Title 0 AM 1 . AM <br /> I I • © O O PM I 1 S Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whol� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 5 <br /> 7 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned 0 OTR Q 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 40 Other '\TC'C\�0C- ve�x\e v <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 O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 0 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 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators +In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> z <br /> Comments p �! <br /> Inspection Form Included: <br /> Comments Included. �• <br /> Bus' ess Rep's Signature Phone Number nspe tor's Signature Phone Number <br /> INSTRUCTIONS ON BACKCorrect: Incorrect: EXAMPLE 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />