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02 Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 11 -1176741 <br /> CalRecycle covery(Cal Survey Form — Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) � V 4,:_ 1J ��1 `J' <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection- �1 Inspection Type(Fill one) <br /> Site Suffix: 1 V ' * Routine Q Re-inspection Q Referral Q Observation <br /> LocalJ® 1 i (-/� If Referral,choose referral type(Fill one) <br /> Identifier: an Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> s 0,\0, �9 ,� �� ,,a , 3 <br /> Physical Address ,(� Q ( FSA <br /> AInspection Date <br /> Time In 'rime Out J <br /> Business Rep Title <br /> I t AM I (� AM <br /> l ' l 5 OPM � ' ` V QPM <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 /> ®Active Q Passenger • Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair O 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 Q Other <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 Q - Q Notice Of Violation Q Extension <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 / 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 EXT) 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 /> Lu <br /> Lu <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators (a In Compliance-No Violations o <br /> Q Q Other:§ _ 1 <br /> Comments s k� 4�ny .. \0 -�ID V,�)l� �1tj <br /> V�ah1 r,jxs01 U�.f e.c.1S 0� (.,U.lvw O. <br /> Inspection Form Included: Q - t <br /> Comments Included: 41 e �j <br /> ` , ` <br /> Business Rep's Signature Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: _ 47 E X A M 1 ; 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L ® ■ <br />