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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1196372 <br /> Dept.of Resources RecycC.IRling g and Recovery(CalRecycle) Su rvey Form - Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- + e1 _ Q 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: Sk Q a C(,u✓) Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or FacilityName <br /> Inspected By Inspector <br /> ��iI m _ <br /> (_Mn ��f 1- Z4VCn <br /> Physical Address <br /> I /� c Inspection Date <br /> L <br /> ` ( C l SA ISILO Time In Time Out t <br /> Busi 1@,>� Rep,'S ���Imo- -� Title <br /> 16 m�7��y��r -. l 3 () O AM a o �l 0 AM <br /> GY' to T�S � 1 C�'lX� I �/'�f�l�j^V ® PM CJ ® PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (� <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � v�, � <br /> SActive ® Passenger ® Generator 0 Outdoor <br /> O 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 P(BAutp 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 ��r 1,J�� m1c- <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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m Ffl <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 /> a <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 /> 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 1 Q 1 Other:§ <br /> Comments — <br /> jq Ail .0 <br /> Inspection Form Included: O <br /> Comments Included: * <br /> e ' n ne u 1 pe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: 7X*7q7]I E I X I A M P L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co.y: ® ■ <br />