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Waste Tire SAey & Inspection Reporeinspection Report Number <br /> CalRecycle State of California 11 — 1245344 <br /> Caycling lndRece 181 very(v. 10) 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- � � � � t ` � , � � � Inspection Type(Fill one) <br /> Site Suffix: `� • Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �r J C' Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> ca-ccy\ \44kie-1 G W <br /> -Q <br /> Physical Address / AAT 1 <br /> �� Inspection Date <br /> 7 Time In (� Time Out <br /> Business Rep Title u O AM 1 O AM <br /> PM e PM <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 /> b 0 Active Q Passenger 4'Generator ' Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler I& Indoor3 <br /> O Q Inactive 10 Truck <br /> Longitude - Q Planned Q OTR Q End-Use a Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 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 /> 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 EXE N <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <br /> Q O 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 dpin Compliance-No Violations o <br /> Q Q Other:§ p _ <br /> Comments V �� ���� f i v�SPGGr� <br /> �� � O�y`'� �'��S <br /> /3tA, �lCl.'t�� <br /> �2 3 <br /> Inspection Form Included: Q _ <br /> Comments Included: — <br /> *A,in IR4,p' Phone Number InspectdFs Signature Phone Number <br /> �,( 62081 <br /> INSTRUCTIONS ON BACK Fcorrect:0 Incorrect: X � NJ E X A M P L E 1112 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />