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02 Waste Tire S%., ,iey & Inspection Repor, inspection Report Number . <br /> cal Recycle State of California 11 - 1226244 <br /> CalRecycle Recovery <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A -Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- p Inspection Type(Fill one) <br /> Site Suffix: d ( t ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalC J� If Referral,choose referral type(Fill one) <br /> Identifier: Sc tr\ scc- "Y" 6G0q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ( Inspected By Inspector <br /> } <br /> Physical Ad ress <br /> ll� i lollLl 0-r <br /> . Y <br /> / Inspection Date <br /> —7 / I 1 / t <br /> /c Time In TimeOut <br /> Business Rep Title r0 AM 0 AM <br /> PM r� 5- ® PM <br /> f, G CT til I"K J ti Z�'n'1 - <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 ® Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use I Q Container <br /> Business Type(Fill ail that apply) <br /> ® New Tire Dealer Q 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 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 /> 04 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle R <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 /> 2 <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators SoIn Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> i <br /> Inspection Form Included: Q <br /> Comments Included: ®- <br /> slness Signature Phone Number p tor's Si ture _ Phone Number <br /> ----- - - 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: E X A6 L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop ; - © ■ <br />