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Waste Tire Survey & Inspection Report Inspection Report.Number ■ <br /> CalRecyde State of Californiacle 131( 11 - 12 4 2 2 3 7 <br /> Dept of Resources Recycling and Re ove�CalRecycle) Survey Form - Page 1 - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site SuNix: Q {� - �l ] 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. S�—'Td == <br /> 0 n —� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 33 _ E, LMA=Q --j <br /> Physical Ad ss <br /> beet <br /> Inspection Date <br /> 952a5 { 1 <br /> City �State Z1P Code Time in Time Out <br /> Business Rep Title 5Iol : <br /> M\� o <br /> AM 4PAM <br /> O PM [a : QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> r j <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) . (Fill all that apply) <br /> } ! I i y {Z <br /> J { , i 1 _ l le Active Q Passenger 0 Generator IS Outdoor <br /> �( 1� Q Closed Q Altered <br /> GPS Latitude M- LLI-1 v�_ JQ Hauler Q Indoor <br /> 4_1 <br /> O Plannd Q OTR � se QQ Inactive I& Truck <br /> ILongitude - I iii 1 I 1 1 I+ Q End-Use Container <br /> I <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair I@ 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 T <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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadllne <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m I 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 E)C7) 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 /> Tc <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 1 Other.§ L <br /> Comments <br /> 04- <br /> Inspection Form Included: Q -7�� �rSignature <br /> Comments Included: . Business Re nature Phone Number Inspe Phone Number <br /> - 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect:�� V EXAMPLE 1 2 3 <br /> Chila y:CalRoc e Yellow Copy:Operator Pink Copy:LEA <br />