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Waste Tire-S*Vey & Inspection Repo Inspection Report Number <br /> Dept of Resources CalRecycle RecycliStateng cRovery(CalRecycle) Survey Form - Page 1 I1 - 117 6 6 9 0 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: / J13 1 17 -7 6 T' ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. �"T17Ct�jf.Cs'sv a Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name // yv Inspected By Inspector <br /> Physical Address <br /> Street Inspection Date <br /> 4.,5,;t C3 4 <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title . © Q O AM ®AM <br /> [�V] PM <br /> ® PM O I � O <br /> i ppp�y�(( 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 /> � <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> ® Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> (��� O Q Inactive Q Truck <br /> Longitude - , I I I Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> L 1 <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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility. ENFORCEMENT STATUS <br /> V'j A IHAuLING-ANDM4NIFIEST 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 <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) <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 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 Other:§ <br /> Comments <br /> zzcm�%nn � Cly„I,- :erm �yll�.t.✓1 ve <br /> Inspection Form Included: Q <br /> Comments Included: ® <br /> /iYtGci Oj?G>rCc.f-QY C2o4) i./6$-06Z <br /> — <br /> Business Rep's Signature - Phone Number nspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X IF, d nn E .x A P L E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />