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Waste Tire Survey & Inspection Repori Inspection Report Number <br /> CalRecycle State of California 11 �-- 1226520 <br /> CalRecycle1a1(Rev.y(Cal Survey Form - Rage -1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) V A Y BLUE O R BLACK INK PEN , <br /> Part A-Surve <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: , L-� �� L_ ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <efty_' Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> o l <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> �' ( - 2 0 <br /> tTS 5- c m co✓ (f )" <br /> Inspection Date <br /> r.3 �✓ 1 l <br /> Time In Time Out <br /> Business Rep Title � � � 0 AM n 0 <br /> AM <br /> �• I OPM ' (1' if PM <br /> !- &-cotone- �,6 Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> Active ® Passenger I& Generator Q Outdoor <br /> a Al IA- <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q 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 40 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 Q Notice Of Violation O 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 / m <br /> N <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18 - (Required for NOV or EXT) N <br /> 459.2.1 Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <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 /> s <br /> Comments <br /> Inspection Form Included: Q Zo -131 D;Z0 -'j - <br /> Comments Included: B 'ness Rep's Signature Phone Number 7 I is gnature Phone Num er <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:a Incorrect: E X A L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop : © ■ <br />