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0 Waste Tire i1.. vey & Inspection Rep Inspection Report Number ■ <br /> CalRecycle State of California( I 1 - 1245163 <br /> CalRecycle (Rev.Recovery <br /> Survey Form - [gage 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' 2 o o Inspection Type(Fill one) <br /> Site Suffix: 3 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0-1 <br /> 1 6 vA 0 CHP Q CalRecycle Q Complaint O Educational Visit Q Other <br /> Business or Facility Name �pInspected By Inspector <br /> Physical Address ` 0 <br /> S 33 Wc��cdkr' <br /> ��A CS V_\ Inspection Date 10 <br /> 5 C �52dS <br /> Time In Time Out <br /> Business Rep Title O AMO AM <br /> ' &PM v 4W PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger Generator 0 Outdoor <br /> O O Closed Q Altered <br /> Latitude <br /> GPS O Hauler Q Indoor <br /> 0 Q Inactive Truck <br /> Longitude — O Planned 0 OTR O End-Use O 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 4& 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 /> 0 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Extension <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> 0 Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> O O 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 /> 0 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement � <br /> 0 Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators o In Compliance-No Violations <br /> 0 Q 1 Other:§ <br /> Comments IS— �t�0 r AQ Vn c Ay1 +t% e <br /> Inspection Form Included: O <br /> Comments Included: 0�At-slote XZW450k 20 f+� <br /> 3z8 I <br /> Business Rep's Signatu Phone Number nsp toy's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: 7X74 q EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />