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Waste Tire Survey & Inspection Report Inspection Report Number <br /> cle State of California <br /> CalRecycle CalRecycle (Rev. Survey Form - Page 1 I1 12 3 0 2 7 2 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- -7 -7 <br /> ^, l Inspection Type(Fill one) <br /> Site Suffix: / o Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier:h C11�:�.^ C � Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By 1 Inspector <br /> Physical Address <br /> Inspection Date <br /> �-dc-\-o�n C q5 2d� <br /> Time In Time Out <br /> Business Rep Title ` (. 2 O AM y O AM <br /> D�� S , 0 PM 1 ® PM <br /> �� . �aotiis <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 /> df Active Q Passenger a Generator Q Outdoor <br /> Q Closed Q Altered j� <br /> GPS <br /> Latitude Q Hauler Q Indoor <br /> � Q Inactive Q Truck <br /> Longitude — Q Planned 40 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 !"le.�\ <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 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 <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 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 /> 2E <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 <br /> *in Compliance No Violations o <br /> Q 1 Q 1 Other:§ <br /> Comments K.Uta'lyr2r Y, oy� Thy <br /> Inspection Farm Included: <br /> Comments Included: 40t� 7 <br /> Business Rep's Signa re Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: E X A M P L E 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />