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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California <br /> (Rev. <br /> R 11 - 1229990 <br /> CalRecycle h cover (Cal 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 /> TPI - Inspection Type(Fill one) <br /> SiteSuffix: 17 65 S SO 1 Routine O Re-ins <br /> Pection O Referral <br /> Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: S C�v Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> c�.ln �a a�v�,n �.�j <br /> Business or Facility Name {gyp 1 // Inspected By Inspector <br /> PhysicalddC Cc <br /> 1660 <br /> Inspection Date 03 S <br /> s32 <br /> Time In Time Out <br /> Business Rep TitleO AM _ U O AM <br /> . O o <br /> Ass . 4kPM 0 PM <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 /> i Active Q Passenger 0 Generator Q out oor <br /> O Q Closed Q Altered �( <br /> GPS Latitude <br /> O Q Inactive Q Truck Q Hauler Q Indoor <br /> Longitude — Q Planned 10 OTR O 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 O Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VI A I HAULING AND MANIFEST REQUIREMENTS <br /> O O Q Notice Of Violation 0 Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX ) N <br /> a <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> W <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators I*In Compliance-No Violations o <br /> O O Other:§ <br /> Comments <br /> Gvercef V1 <br /> Inspection Form Included: jM-2 *.Jt <br /> o 469-32A <br /> J <br /> Comments Included: 41 <br /> usin s ep's Sign ure Phone Number Insp ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:t, Incorrect: X 4V] <br /> EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />