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Waste Tire S...vey & Inspection Report. Inspection Report Number <br /> CalRecycle State of California 11 - 12 2 6 3 2 5 <br /> CalRecycle 181 Recovery <br /> Survey Form - Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) _ BLUE <br /> Part A- SurveyOR BLACK INK PEN <br /> Business Profile - Inspection Details <br /> TPID- e 1 Inspection Type(Fill one) <br /> Site Suffix: ' `� 1 0 � O 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: 010 j0M ut>\ 011An n Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Q10_ C1-C,(f\ �u�vl� enc,.Physical <br /> Physical Address 2 J I j <br /> ���^ �� ���I� Inspection Date <br /> d Time In Time Out <br /> Business Rep Title l J O AM O AM <br /> I I ® PM All PM <br /> -- - - - - --- - ---- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) /y (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> GPS Latitude o Closed Q Altered'A Q Hauler 1A Q IndoorN�� <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 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 /> 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / Ffl <br /> / 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 EXT) 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 /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities m <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ ] L y <br /> Comments <br /> _ A irf c t <br /> - I O V10lgaS <br /> kf� pS ( us�o- ' Cn <br /> ur)eer <br /> 61��to ss I(1(LL 0, A d Ja rs <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number �1 ,peis Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: _6� E X A M P L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L © ■ <br />