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02 Waste Tire Su. ,✓ey & Inspection ReporOnspection Report Number <br /> CalRecycle State of California — <br /> Ccyclin a d R(Rev.y(cal Survey Form - Page 1 I1 1242422 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � � � � Q , Inspection TypeO(Fill one) <br /> Site Suffix: • Routine Re-inspection Referral Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: Stw1 ��5 -g V;� �V�.L ' Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v \'� Inspected By Inspector <br /> Physical <br /> C�I - <br /> Physical Address r� J d <br /> Inspection Date c L / 3 <br /> S�oct�lyd,r� C1� �1S2c�S V v <br /> Time In Time Out <br /> Business Rep Title O AM 2 O AM <br /> Stt�w'c eaC� S • 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 /> i Active Q Passenger 0 Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> 0 Q Inactive 16 Truck <br /> Longitude - Q Planned Q OTR 0 End-Use 0 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 e <br /> Q Service Station Q Hauler Q Agriculture Q Shredder . Other TC0.\�2c 52�`v�cSZ1Ce G.s <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date�nS M2-c / 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 /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> O 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance-No Violations o <br /> O O Other:§ <br /> Comments <br /> Set Cc:, <br /> Inspection Form Included: Q <br /> Comments Included: <br /> usiness Rep's Signature Phone Number Insp ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EXAMPLE 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />