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® Waste Tire - 'Vey & Inspection Repc Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1226287 <br /> CalRecycle (Rev.Recovery <br /> 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- / Inspection Type(Fill one) <br /> $ite Suffix: Gs61 3 S 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: -�-��iq�.t7 w 0 CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �_j V <br /> Inspected By Inspector <br /> Physical Address / "/ <br /> A A <br /> 3� lv �i�isV"1 �4 t—r c + <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AM ®AM <br /> 1 QPM S O QPM <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 /> Z ® Active 0 Passenger ® Generator ® Outdoor <br /> Latitude OO Closed Q Altered <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair O Trucking Fleet Q Government Q Retreader Q Dismantler O 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 0 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 O Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O ® 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 N <br /> O O 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 /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement � <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations o <br /> Other:§ <br /> Comments <br /> CA A <br /> Inspection Form Included: O <br /> Comments Included: ® - - - - <br /> - Business Rep ture Phone Number Inspector, gnature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A M L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L <br />