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Waste Tire Su, vey & Inspection ReporAnspection Report Number <br /> CalRecycle State c cle 181(R10/1 0) I 1 - 1242281 <br /> CalRecycle (Rev.Recovery <br /> Survey Forms - Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> _ <br /> Business Profile Inspection Details <br /> TPID- Inspection Inspection Type(Fill one) <br /> Site Suffix: i C) q -1 o I • Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: yah 3-a ac\tV-\ V Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> S Wz G1?_ <br /> Physical Address <br /> Inspection Date O 2 / ® 7 / <br /> �eOr Time In Time Out <br /> Business Rep Title , O AM 2 O AM <br /> i PM 1 ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole(/PTE) (Fill one only) (FII all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Passenger 0 Generator Outdoor <br /> Q Closed Q Altered <br /> ��� Latitude Q Hauler � Indoor <br /> O Q Inactive Truck <br /> Longitude — Q Planned 4& OTR Q End-Use ® Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> . Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q 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 /> 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or Exn6.1 <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <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 Q Other:§ <br /> Comments <br /> �S y <br /> 04 <br /> Inspection Form Included: <br /> Comments Included: ��� / 2o9_ g_ � <br /> usmess s Signature Phone Number '-Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X7*q�]jEjXjAjMjPjLjEj 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA. <br />