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Waste Tire Survey & Inspection Repok Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1226700 <br /> Caycling le 181(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- S , f / _ ( Inspection Type(Fill one) <br /> Site Suffix: 10 Q Routine Q Re-inspection 1* Referral Q Observation <br /> Locali If Referral,choose referral type(Fill one) <br /> Identifier: 5(,(0 �lj G [Al,n l,Q'U,n Q CHP ® CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Te-6 G _ v <br /> Physical Address 3 E5�6Y <br /> � Inspection Date l t / V <br /> l' Time In Time Out <br /> Business Rep Title O AM O AM <br /> QPM QPM <br /> 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 /> �(f Q Active Q Passenger Q Gen/e�rator Q Outdoor <br /> Latitude 0 ® Closed Q Alter6 JJA Q Hauler�� Q Indoor GPS <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 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 Q Other NIA A <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> QQ 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 a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E)C7) N <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 /> 2 <br /> W <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:§ z <br /> Comments A I I jOnA U l tJ1 s 0 W <br /> -- - - o_n �l i olLlT 1U_fl( o S a[,_qS Uncar n- I �1 <br /> —N >JTc _t.le <br /> a. N-W 01wni, k a � -((,1—LD. 11 ebbsr-a 1. <br /> Inspection Form Included: Q <br /> Comments Included: Q �U� ��� I7 <br /> Business Rep's Signature Phone Number Inspe is Signature - Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® . <br />