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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California 11 1226588 <br /> CalRecycle Recovery ev.10/10) <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> t A- Survey BLUE OR BLACK INK PEN <br /> Jness Profile Inspection Details <br /> TPID- J I - O j Inspection Type(Fill one) <br /> Site Suffix: (9 1 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: J Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - { 1 Inspected By Inspector <br /> N oPV�n 6a4 aQ�. ocr, t�nur�ccrt�ill 3 C, <br /> Physical Address <br /> L1 �533a Inspection Date <br /> 0�tcA <br /> Time In Time Out <br /> Business Rep TitleO AM 0 AM <br /> 3 • PM vC ® 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> GPS Latitude O ® Closed Q AiterAe /A Q HauNA Q Ind <br /> O Q Inactive Q Truck <br /> or <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> R-isiness Type(Fill all that apply) <br /> Vew Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> J 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 Other nvn <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 N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXn N <br /> v <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <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 ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments II <br /> I1,6,/A,4C�"C L 11 l7ll t1� OJl'f b e I <br /> ate <br /> Yy_ j o l 1'o-i 5 y r d fi_A S (Y (O n LQ.1 n <br /> ,Oection Form Included: Q , <br /> Emai <br /> Comments Included: ®- - - -- -- - - <br /> Business Rep's Signature Phone Number Inspec 's Signature Phone� Number <br /> �,( <br /> INSTRUCTIONS ON BACK �Correct:0 Incorrect: � N EXAMPLE 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />