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Waste Tire Sup vey & Inspection Report Inspection Report Number ■ <br /> calRecycle State of California I 1 - 1177733 <br /> Caycling le 181(Rev.y(Cal Survey Form - Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Surypy BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� � d � � _ O � Inspection Type(Fill one) <br /> Site Suffix: 10 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Y) 'JC O Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �V Inspected By Inspector <br /> Physical Address <br /> 155b N . C1 0,VA RCk <br /> ���Y CA <br /> 5,3c) I Inspection Date S f / r 3 <br /> Time In Time Out <br /> Business Rep Title 1Q �l 0 AM ®AM <br /> � V QPM I ' � © 0 PM <br /> S`naWy� SC�hetGe� �3�� M(�t� t� <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 /> 7 ' 90 Active Q Passenger ® Generator Q Outdogr,, <br /> GPS Latitude Q Closed Q Altered Q Hauler Q Indoor <br /> o Q Inactive 0 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 ® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Q Q Notice Of Violation Q Extension <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> v <br /> 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 /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <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:§ f 1 <br /> Comments g O v b he. W a.SA-e- kAm, 1 h S A1. ccA zo+n dlol k e— n yN Ty i S CJ��'K <br /> � �C)wkyl �aS_ I�a�C9-\ <br /> my-' _ <br /> e Co �S a. 2 <br /> Inspection Form Included: <br /> Comments Included <br /> Business Rep's Signature Phone Number Insp ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X 1.g E X A M P E 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />