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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California1( v. 1 1 - 1226602 <br /> CalRecycle lndRec very( al Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A-Survey_ _ -- -- — <br /> Business Profile Inspection Details - - <br /> Inspection Type(Fill one) <br /> TPID- <br /> Site Suffix: -[ L^ O ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ``- If Referral,choose referral type(Fill one) <br /> Identifier: ��� —C,.,IC6N1-1 4V1- <br /> v,1z`l O CHP O CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date `7 / C) L <br /> ���S Time In tT Ti4n.�/e Out <br /> Title ^ AM <br /> Business Rep t 0 PM 0 PM Business Role Storage Type <br /> G lc 1/C A �c:.�c 5 <br /> �_ Operational Status Tire Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) _6LQ Active i0 Passenger ® Generator 0 Outdoor <br /> - _--- o <br /> 0 Closed Q Altered <br /> GPs Latitude Q Hauler I Q Indoor <br /> o Q Inactive Q Truck i <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer ® 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 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 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 O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / Ffl <br /> N <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXT) N <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days _ a <br /> N <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire HaulersZE <br /> Q Referred/CalRecycle Enforcement ZE <br /> W <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities - - - -- <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments r'�� i' A/0 <br /> 7h7'G� r,�- �sr,�1�rrt.5 A�n �Gs i' .Svv►c.IG',�•�✓v� 5 .'� ,r2 p !�a`"' �-�'�' <br /> C'4- S <br /> I <br /> 7o? ( 60 <br /> tee, <br /> Inspection <br /> Form Included: Q <br /> Comments Included: Q <br /> Business Rep's SignaturePhone Number Aer' gar Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: � E1 2 3 ■ <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br /> ■ <br />