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Waste Tire Su. ,iey & Inspection Reporiblnspection Report Number <br /> CalRecycle State of California I 1 - 1242163 <br /> CalRecycle <br /> ndRec v.very(10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Q 6 Inspection Type(Fill one) <br /> Site Suffix: u-1 5 [7 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S0.r Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name \/ r W Inspected By Inspector <br /> ems. _ © 1 ���� <br /> Physical Address <br /> l?000 �, �,�„�► 120 <br /> Inspection Date 0 —/ <br /> Q: boy <br /> Time In Time Out <br /> Business Rep Title 1 O O PM PM <br /> 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 /> 40 Active Q Passenger Generator 0 Outdoor y <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 46 Indoor 2 <br /> O Q Inactive Q Truck <br /> Longitude – Q Planned 0 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA 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 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 EXE n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <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 In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments V.�j \,9c_,S _ ' k �Y�SQ ��GY� C�Y�S �Y� "t�n�S &_Wk n <br /> t Nte 0..S 6 &1A <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business ep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correct: Incorrect: X7*V EXAMPLE 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />