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Oa Waste Tire Su,vey & Inspection Reporn Inspection Report Number <br /> CalRecycle State of California I 1 - 1245162 <br /> CalRecycle cover (CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Surve�i _._ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 4 - Inspection Type(Fill one) <br /> Site Suffix: 6 I d 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: '56 <br /> P+ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �— Inspected By Inspector <br /> {� <br /> Physical AdddrressMa �v� Q l MA��V <br /> �ZSc� ?� • �Scol.\ov� 'fie.\low KAT <br /> CA C, Inspection Date <br /> Time In Time Out <br /> Business Rep Tit0 AM 0 AM <br /> AAeC�` y 5 . PM Z d '* PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) / O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 4P Active Q Passenger • Generator Q 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 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 & Otheru� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCE ENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q 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 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 EXE N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <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 t _ VAn C_� <br /> c2c4 a�S cry- c�enc a c✓\ <br /> Inspection Form Included: Q <br /> Comments Included: e'l - J <br /> siness Rep's Signature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A M P L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />