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Waste Tire Su, vey & Inspection Report Inspection Report Number <br /> CalRecycle State of California — <br /> yclingCalRecycle R(Rev.Recovery <br /> Survey Form - Page 1 I1 1210526 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> i <br /> Site Suffix: �r `� 7 <br /> (G L ( C `I. Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: sLl/` 1/IV\ C (7 O CHP Q CalRecycle 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> P ysical Address ( < j ��L <br /> Inspection Date <br /> 6('�Q� <br /> ' �`� Time In Time Out <br /> Business Rep Title0 AM 0 AM <br /> ) ' 9 _ ®PM a © ® PM <br /> fC�!'V�C c.G�WG i G i C' V{G)ov7>r 3G <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whale/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Pass nger 0 Generator Q Outdoor <br /> GPS <br /> Latitude O ® Closed O Altered O Hauler Q Indoor <br /> O 0 Inactive Q Truck <br /> Longitude - Q Planned O OTR O End-Use O Container <br /> Business Type(Fill all that apply) <br /> * New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body 0 Car Dealer Q Collection 0 Crumb Rubber <br /> 0 Service Station Q Hauler 0 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 <br /> �Notice Of Violation � Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle m <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> O 0 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 EXT) N <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators &n Compliance-No Violations o <br /> O 1 Q 1 Other:§ <br /> Comments Q �" <br /> �4L1 AVL fN150 YG Atc, J/,d c.,,�::wA YlOCC7�> 711%-Z <br /> ce- 16F <br /> Inspection Form Included: Q S7 <br /> — <br /> Comments Included: Q � � ��7�S <br /> iness ep's Signature Phone Number 1 p t 's ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: W EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />