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I' <br /> Waste Tire Survey & Inspection Reportp p <br /> Ins ection Report Number <br /> calRecycle <br /> State or11rNa 11 - 1230093 <br /> CalRecycleclet6l'(Rey.10/10) Survey Form - Page 1 <br /> Dept.or Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> --------- -- --- ---- <br /> TPID- Inspection O w L � � � � � Inspection Type(Fill one) <br /> Site Suffix: a Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: (J <br /> _�0 !AV_ ____ - 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 /> p Inspection Date I !• <br /> Time In Time Outf is <br /> Business Rep Title 0 AM c*AM <br /> ` 4 QPM 1 I ' ' S 0 P (: <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 /> 9( Q Active Q Passenger Q Generator Q Outdoor I. <br /> O IS Closed Q Altered ✓" <br /> GPS Latitude Q Hauler �ndo r <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 Q Other <br /> Part B- Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS li <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 lire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m L <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q (Required for NOV or EXi) :• <br /> 14 CCR 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 /> W <br /> Q O 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 /> go lU I U I Grner:s I <br /> Comments <br /> Or .estSC��c�cYn <br /> Inspection Form Included: Q <br /> Comments Included: - <br /> Business Reps Signature Phone Number Insp d ctors Signature Phone Number <br /> INSTRUCTIONS ON BACK orrec • Incorrect: V EXAMPLE 1 2 3 s2os1 <br /> White Copy:Ca1R _ Yellow Copy:Operator Pink Copy.LF�1 ® ■ <br />