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Waste Tire Survey & lnspecVon 1"9epon Inspection Report Number <br /> CalRecycle State of California I 1 - 12421. 66 <br /> CalRecycle (Rev. (Ca[ Survey Form - [gage I <br /> Dept.of Resources Recycling anddRecovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- r✓ Inspection Type(Fill one) <br /> Site Suffix: ` ?j `� -2- •Routine Q Re-inspection Q Referral Q Observation <br /> Local ^�� �^ If Referral,choose referral type(Fill one) <br /> Identifier. V% ``06-�"'' 1. 60L'V1/ 11 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I Inspected By Inspector <br /> Physical Address An <br /> n,� R Inspection Date -7 / L � <br /> Cil `530'Ll Time In Time Out l <br /> Business Rep Title 1 ' AM _ ®AM <br /> l <br /> l 0 C�- O PM `X J O PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) y <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � <br /> v IP Active ® Passenger ® Generator o Outdoor <br /> GPS Latitude O0 Closed Q Altered <br /> Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR 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 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 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> Q 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q 0 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 /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> W <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 0 Other:§ - <br /> Comments <br /> S <br /> Inspection Form Included: 0 <br /> sr � <br /> Comments Included: <br /> Business e Ign ig ture Phone <br /> re Phone Number In p ct .3 <br /> R ' or' Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: L 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C p ® ■ <br />