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Waste Tire Su. ✓ey & Inspection Repon Inspection Repot Number <br /> CalRecycle state of California 11 - 1229968 <br /> CalRecycle Survey Form - Page 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- � � Y � � � Inspection Type(Fill one) <br /> Site Suffix: "1 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S01y\ jr\ C(3v A�y Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l <br /> m Inspected By Inspector <br /> Cd2� 1 'C v.���`r �cL�S� L—L'C ^l <br /> Physical Address \ ,1 M <br /> ekT <br /> Inspection Date -2S <br /> Time In �J Time Out✓✓ <br /> Business Rep i Title l I$AM 1 1 ( I ® ®AM <br /> � c <br /> : J O O PM ` I `-) 0 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 /> 0 Active Q Passenger * Generator 0 Outdoor <br /> o Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 4D 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 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 0 Other pa'-Jt-6 40 nc r <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 / m / IT <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <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 1 Q 1 Other:§ _ <br /> Comments \2tz�``�,V, <br /> Inspection Form Included: Q <br /> Comments Included: �*BusWie ;R *4_7_77: <br /> - <br /> p's ign ure Phone Number Inspec or's Signature Phone Number <br /> _ <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: XA � NJ EXAMPLE 1 2 3 62081 <br /> . White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />