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Waste Tire vey & Inspection Repori, Inspection Report Number ■ <br /> CalRecycle Cte of alRecyclel181nia(Rev.10/10) I1 - 1176802 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A- Survey _ — BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ Inspection Type(Fill one) <br /> Site Suffix: �j �) j Q Routine Q Re-inspection Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �CA V1 QI-In ��GY2� Q CHP Q CalRecycle 10 Complaint Q Educational Visit Q Other <br /> Business or Facility Name / Inspected By Inspector <br /> Physical Address 0 Ic 0 <br /> L, J� <br /> I-J. <br /> Inspection Date <br /> J �* 615 l Time In Time Out l <br /> Bus,i ss Rep/ Title /� O AM O AM <br /> ( C G Y DR1 I: Y� V to PM d ® PM <br /> Cwt f C� <br /> J V t c� Operational Status Tire Type Business Role Storage Type <br /> ' ' © (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ® Active ® Passenger Generator 0 Outdoor <br /> O 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 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 /> 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 ® Other —7 y j YystrJ 6u-h}i--, <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS l <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 o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <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:§ <br /> Comments <br /> 5 <br /> Inspection FormIncluded: Q <br /> C( rc c- <br /> Comments Included: <br /> Busi ess R s Signature Phone Number In or Si ature Phone Number <br /> �,( 62081 <br /> INSTRUCTIONS ON BACK FCorrect_�* Incorrect-:X � N E X A- L E 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop •L © M <br />