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Waste Tire 96l<vey & Inspection Report 'Inspection Report Number <br /> CalRecycle State ofCalifornia <br /> Rev.10/10 ■ <br /> y ( Survey Form - Page 1 I1 1196406 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Sart A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 0 Q � � _ O 1 Inspection Type(Fill one) <br /> Site Suffix: �J I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S o c) J OCI LL"i� CO l A1) Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> er � S <br /> Cc^n ?Ur� <br /> Physical Address <br /> IL <br /> Inspection Date O 3 1 3 <br /> Time In Time Out <br /> Business Rep Title q O AM l O AM <br /> ® PM � t � ® PM <br /> J 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 /> 0 Active Q Passenger 0 Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler A Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 /> a <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 Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <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:§ L <br /> Comments `—O \ftp <br /> N o -v;n1AA-i b.S 03 ck f Qu,S 0i (-bflCef <br /> Inspection Form Included: Q / Q /}��.� ��` �1 <br /> Comments Included:® oq - I l0 �� <br /> Busi VsRep's Signatur Phone Number Inspe t is Signature done Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A M P (g 1 12 3 I 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C py: E �� 0 <br />