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Waste Tire SGrvey & Inspection Repon Inspection Report Number <br /> Cal Recycle state of California I 1 - 1210553 <br /> CalRecycle (Rev.Recovery <br /> 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- Inspection Type(Fill one) <br /> Site Suffix: ` -7 0 1 ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1; Inspected By Inspector <br /> ��ss I <br /> Physical d'd',ss ' ��� T �1' t �� S <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title AM AM <br /> a� 0 0 CPM , 0P <br /> - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole TE (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> IS Active 0 Passenger 4 Generator ®Outdoor <br /> GPS Latitude 0 Closed 0 Altered 0 Hauler 411 Indoor <br /> 0 0 Inactive ®Truck <br /> Longitude - 0 Planned ® OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer V 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 /> Bart 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 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / T <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) n <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement g <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> I&In Compliance-No Violations o <br /> 0 0 Other:§ <br /> z <br /> Comments <br /> Inspection Form Included: �IlD 4-7 <br /> Comments Included: 0 <br /> Business Rep's Signature Pho a umber In ecis Ign ture Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: 7** v l E X A L 11213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C py: ® ■ <br />