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Waste Tire Sup vey & Inspection Report Inspection Report NumberStte of <br /> ■ <br /> cal6ecycle CaaRecyclel' ia 181n(Rev.10/10) 11 - 1196331 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form — Page 1 <br /> Sart A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- hh� 1 Inspection Type(Fill one) <br /> Site Suffix: 3 �j V ` ® Routine Q Re-inspection Q Referral Q Observation <br /> Local \ If Referral,choose referral type(Fill one) <br /> Identifier: J o(:c .�� Gr��.vt Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name // Inspected By Inspector <br /> Physical ddres�`RJ q _ ( (� ,tj(�/� <br /> 1 013 SIC> 3. i4rA <br /> Inspection Date <br /> f1G� C� ti� (A Time In Time Out t <br /> Business Rep Title O AM 7 ,rte O AM <br /> G� ® PM J V * PM <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 ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use ®1 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 <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 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 <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 /> W <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 (a In Compliance-No Violations o <br /> Q Q Other:§ <br /> i <br /> Comments <br /> r <br /> Inspection Form Included: Q 110 �(j C9 l,( <br /> l Q 6:?-Y4b 7 <br /> Comments Included: <br /> Busine4s Rep's Signature Phone Number 41nsct, s Sig tur Phone Number <br /> � <br /> INSTRUCTIONS ON BAC Correct: Incorrect: � EX A�M 1112 <br /> 3 62081 <br /> ■ hite Copy:CalRecycle Yellow Copy:Operator Pink Co y: LA 0 <br />