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Waste Tire Su. vey & Inspection Repo Inspection Report Number <br /> State of California <br /> CalRecycle CalRecycle 11 - 1230280 <br /> Dept.of Resources Recycling and BRecovery(CalRecycle) Survey Form - Page 1 <br /> Part A- Survey—_ _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- inspection� � � � � _ � I Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sck'Vti �ao Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> Physical Address 3 - 1 d 1 !_l ATT V <br /> Inspection Date /� 1 � 67 <br /> 7 Time In V Time Out <br /> Business Rep Title u O AM O AM <br /> / 1 0 PM O PM <br /> t "" Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) �-5 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active ! Passenger 0 Generator 0 Outdoor <br /> 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 /> Q New Tire Dealer 0 Auto Repair Q 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 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 O 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 E)C7) 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 /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> Q Q Other:§ <br /> CommentsOL 1S �Q <br /> Inspection Form Included: Q ( UI) ')S__gwr �/ 3 <br /> Comments Included: Aq <br /> Business Rep's Signature Phone Number Inspec or's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: \ 7d E X A M P L E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />