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Waste Tire Su, vey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 - 1245012 <br /> CalRecycle <br /> ndR(Rev.Recovery <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> 'art A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- O � Inspection Type(Fill one) <br /> Site Suffix: ` � 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local /- If Referral,choose referral type(Fill one) <br /> Identifier: �(�� ��j �\Y, ( v Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v� <br /> Inspected By Inspector <br /> Physical Address <br /> ►gZ((� S• �'�ac�o�Y. SET, <br /> I r Inspection DateC) S / 1 1 1 -5 <br /> C1� )-,->3 Time In Time Out <br /> Business Rep Title f 0 AM (0 0 AM <br /> 1n� { ' 5 C) 0 PM V 40 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 /> 19 ID Active Q Passenger Generator Q Outdoor <br /> O Q Closed Q Altered WA <br /> GPS Latitude Q Hauler Q indoor <br /> o Q Inactive Q Truck <br /> Longitude — Q Planned 40 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) fimu_ <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 /> n� �� vein;cue <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other ,V,d1_C -111-i� ea�ks <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 <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 N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <br /> Lu <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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 ± L ���,� �Y.��P _ . "t1�� `T__" V�2 C�V� ..► C' '. <br /> Inspection Form Included: <br /> "1 <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspe or's§ignature Phone Number <br /> �-�( <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: \/ � NJ E X A M P I L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA �� ■ <br />