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t <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California ■ <br /> CalRecycle nd R(Rev.y(Cal Survey Form - Page 1 11 - 1196433 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ^5� Inspection Type(Fill one) <br /> 3 <br /> Site Suffix: l 5 6 Lt 3 3 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. ISCXA �+/,,� �i/Vl,� Q CHP O CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> CAf � Inspection Date C2 <br /> � Time In Time Out <br /> Business Rep Title *AM I Q AM <br /> \__ l U : 3 0 oPM C 6S oPM <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) S (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active &Passenger ®Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ® 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 I A 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 /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / ITI / M <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <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 /> f <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 In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> Inspection Form Included: <br /> Comments Include - -� <br /> ,%416's signature Phone Numberne i ature Phone Number r <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: ® � E X M L E 11213 62081 <br /> 0 White Copy:CalRecycle Yellow Copy:Operator Pink Copy L <br />