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1 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> Cal Recycle State of California 11 - 1226335 <br /> Cay]Recycle <br /> ling let8l(Rev.y(Ca] Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A - Survey BLUE_ OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- inspection_ I Inspection Type(Fill one) <br /> Site Suffix: ` S <br /> ® Routine Q Re-inspection Q Referral Q Observation <br /> Locall1 1 If Referral,choose referral type(Fill one) <br /> Identifier: GAA_1)e1_ 1X,1� (014'x11'U1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 3 �l'1 <br /> &AInspection Date / 0 / I <br /> �sz3�� <br /> Time In Time Out <br /> Business Rep Title O Q O AM f 0 0 AM <br /> W�CI� �T� 1 ® PM PM <br /> l o <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 9 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator • Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Truck <br /> Longitude — Q Planned 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 0 Others j <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 /> 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 a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <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 /> 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 0 In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> Comments � ki t � � � <br /> - <br /> �No_ wf- (,u)cUn-_ <br /> Inspection Form Included: 0 <br /> Comments Included: ® 1.444_31W <br /> Business Rep's Signature Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 62081 <br /> E X A P 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co y:L © ■ <br /> ,a <br />