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Waste Tire S.,vey & Inspection Pepoff Is Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1255828 <br /> CalRecycle 161(Rev.y(Cal C U f ]ey F o f?m ® Page `� <br /> Dept.of Resources Recycling and Recovery(CalRecycle) N� I] l! �f IJ II Il IJ Page l� <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- inspection� � � � � - O Inspection Type(Fill one) <br /> Site Suffix: l Q Routine Q Re-inspection 0 Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0.� To al vin_ �v � -- OCHP •CaIRecycle 0 Complaint OEducational Visit OOther <br /> Business or Facility Name 6 <br /> Inspected By Inspector <br /> Physical dress <br /> 7-7n7 Sf Traci '06 , <br /> A ���1 S Inspection Date Q -Z <br /> /_C Time In Time Out <br /> Business Rep Title I 30 <br /> * AM n O Q AM <br /> QPM ` QPM <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 /> Q Active Q Passenger Q G,� `�ernerrattor Q Outdoor <br /> /v <br /> D • Closed Q Altered - A)le/ <br /> GPS Latitude 1 Q Hauler Q Indoor <br /> Q Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR 0 End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder • r^Other f'-4"A_%z{r <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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q O 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 o <br /> Q O 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 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance-No Violations o <br /> Q Q1 Other:§ <br /> Comments <br /> Inspection Form Included: Q 3 <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: _ � JEJXJAJ 111213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop : ■ <br />