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Waste Tire Sur vey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 - 1230319 <br /> CalRecycle 18.1(Rev.y(CalRecycle) Survey <br /> Survey Form - Page 1, <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � Inspection Type(Fill one) <br /> Site Suffix: 1•� ` Routine 0 Re-inspection Q Referral Q Observation <br /> Local /"l' I If Referral,choose referral type(Fill one) <br /> Identifier: SAC) OG.1 u► >, C��n U Q CHP Q CalRecycle 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name L Inspected By Inspector <br /> CJ 1A'(I I �i s Li,c, Jl n5 c) <br /> 3q _ <br /> Physical Address I l <br /> CA ►53777 Inspection Date <br /> (` Time In Time Out <br /> Business Rep TitleC a AM n Q AM <br /> I I L4J QPM I �C. f � 0 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 /> ® Active Q Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive 0 Truck <br /> Longitude – O Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Q Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q O 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 EXE N <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement q <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 ®In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> Comments l ,'�� AnA i N <br /> �OA UA X)\,G Ico <br /> xW<, ' czA <br /> o J 1101 a�i�1 43 S i IA4 ( C 0.1 QJn <br /> Inspection Form Included: Q (w� <br /> Comments Included: ®— <br /> Bu ness Rep's Signature Phone Number Inspe is Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correct:* Incorrect: X (� I EXAM 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co y:L © ■ <br />