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Waste Tiriturvey & Inspection Rent Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1226264 <br /> CalRecycle ndRec(Rev. <br /> very( 0) 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 tails <br /> I TPID- Inspection Type(Fill one) <br /> Site Suffix: r (ice <br /> Q Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> a Identifier: v l � � ,, 1V�, Co'L­ 0 CHP 0 CalRecycle 0 Complaint 0"Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> N&A Pi <br /> Physical Address r r• _ f <br /> Inspection Date <br /> Time In Time Out <br /> 44, <br /> Business Rep Title 0 AM 0 AM <br /> - - 1 , <br /> y <br /> Ll � ® PM QPM <br /> { Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) -{Fill all that apply <br /> Tire Count(Whole/PTE) ; <br /> i <br /> Active ® Passenger Generator Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> j p 0 Inactive Truck <br /> Longitude - 0 Planned OTR 0 End-Use Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer () Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ® Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> i V A HAULING AND MANIFEST REQUIREMENTS <br /> f — - -- 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> PRC 42953-Contracts with Registered Waste Tire Haulers. <br /> i 0 0 § 9 Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> r0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date / FF1 <br /> 1 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle m m W <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXl) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> i <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance-No Violations <br /> 0 0 Other:§ <br /> comments <br /> � L <br /> Inspection Form Included:0 — <br /> Comments Included: <br /> Business Rep's Signature Phone Number --frtspector's.Signature Phone Number <br /> I� INSTRUCTIONS ON BACK Correct: Incorrect: X � V1jEjXjAjMjPjLjEj 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />