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Waste Tire Survey & Inspection Report Inspection Report Number <br /> cle State of California <br /> Cal Rec <br /> Y calRecycle <br /> and R(Rev.y(Ca[ Survey Form - Page 1 11 1210496 <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 t-f � � � � - � � Inspection Type(Fill one) <br /> Site Suffix: ( ® Routine Q Re-inspection Q Referral Q Observation <br /> Local f If Referral,choose referral type(Fill one) <br /> Identifier: SQA ���,� t^ CDut1�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> /� <br /> Business or Facility Name � Inspected By Inspector <br /> / <br /> ' 1MQ/i om"n 1 1 '8+01' HA\je--,-N _ r <br /> Physical Address l 0 , C S( (o T O <br /> (901 <br /> 1 <br /> L O lJl / /� Ct�a�_l)T�J Inspection Date <br /> C /� Time In Time Out <br /> Business Rep Title i y� ®AM l *AM <br /> l t f�. (J QPM J 0 0 P <br /> G1nur es A cue (7L�n<r <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) l q y7 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' I r 0 Active Passenger Generator 0 Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer a 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) 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 /> LU <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:§ <br /> Comments Y-)elf 7%2, <br /> LA) 'I s- o �vl <br /> Inspection Form Included: Q I 16 <br /> • <br /> Comments Included. ® /Cf (f <br /> Business Rep's Signature Phone Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A M P EJ 111213 620811 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop :LEA ■ <br />