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Waste Tire Survey & Inspection Repon Inspection Report Nurnber <br /> CalRecycle State CalRecycle California 11 - 12 2 6 6 0 5 <br /> cyclinandR(Rev.y( al Survey Form - Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- _ inspection Type(Fill one) <br /> Site Suffix: Is Routine Q Re-inspection Q Referral Q Observation <br /> Localc, If Referral,choose referral type(Fill one) <br /> Identifier: JC�t ✓� �Cjr11e�✓ANN CiL4/t Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> i <br /> Physical Addr�c ss <br /> St <br /> 1 q 1 0�, Inspection Date �CA L �o 3 Time In Time Out <br /> Business RepAM <br /> Title ® PM ®PM <br /> Operational Status Tire Type Business Role Storage Type <br /> y� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) a — `V ® Active Q Passenger Q Generator Q Outdogr <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoo <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned ® 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 ® 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 EXn 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 /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle EnforcementLu <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 /> Q Q Other:§ <br /> Comments <br /> Inspection Form Included: Q O( r y20ci- crgZ o d v� 67 <br /> Comments Included: ® Business p's Signatu Phone Number n ector's i ature Phone Number <br /> — 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: � W E X A L E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co :L © ■ <br /> ■ <br />