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Waste Tire Su, vey & Inspection Report Inspection Report Number <br /> CalRecycle state of California 11 - 1210470 <br /> Ccyclin and le 181 <br /> (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- ` 1: ( Inspection Type(Fill one) <br /> Site Suffix: 1 1 I* Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �� f If Referral,choose referral type(Fill one) <br /> Identifier: ��� J ��� ��,(,n 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address '3 1 - 0 �J <br /> V'� <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title ( 0 AM 4%AM <br /> ' ) O 0 PM v O PM <br /> ea� Q,J'I na, 0 vJ ne.,r <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger ® Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> ��� Latitude 0 Hauler Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 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 /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 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 /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> Uj <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 /> in Compliance-No Violations o <br /> 0 0 Other:§ _. <br /> z <br /> Commen((tt`s�� tt ' 1 S 1 <br /> of U <br /> Inspection Form Included: 0 , AZ <br /> Comments Included: <br /> Business ep's Signature Phone Number Insp c or's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: X W NJ I E X A M L 112 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink CA: ® ■ <br />