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�n'si _ <br /> 1-I CV24.Waste Tire SOvey & Inspection Repo port Number <br /> CalRecycle sCalRecycle 181 state of California <br /> CalRecycle 10/10) Survey Form - Page 1 I I1 - 117 6 817 <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 Type(Fill one) <br /> Site Suffix: ®y l� Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. � ��� �(�`, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 3 - D / AJ <br /> L_I_00 C") • C&k_,p!2.o <br /> Street <br /> Inspection Date <br /> L -7 <br /> _ G_9 Q517 6J Time In Time Out <br /> City State ZIP Code <br /> Business Rep Title PM ®PM <br /> L-1_c xvt A- KI.G� <br /> _ Operational Status Tire Type Business Rote Storage Type <br /> — (Fill one only) t (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> Active 0 PassengerQ Generator Q Outdoor <br /> GPS Latitude ® Closed Q Altere <br /> Q Hauler Q Indoor <br /> O Q Inactive Q Truck / <br /> Longitude Q Planned Q 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 L/ {kkv_ �� <br /> L <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT S ATUS <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 <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 EX7) n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <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 Q Other:§ L <br /> _ z <br /> Comments c <br /> ILL a <br /> Inspection Form Included: Q <br /> Comments Included: ® Em <br /> �!Business Rep's S gnae honeber Inspe or' ' i ur Phone Number <br /> INSTRUCTIONS ON BACK Corre : 1 rrect: tV � E X A P 1 2 3 62081 <br /> White Copy: alRec Yellow Copy:Operator Pink Copy:LEA <br />