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Waste Tire Survey & Inspection Report Inspection Report Number <br /> Cal Recycle stat eof c alit ..i-ev.10/10 - 1210505 <br /> ■ <br /> y ( ) Survey Form - Page 1 I1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> iness Profile Inspection Details <br /> r PID- © 1 Inspection Type(Fill one) <br /> Site Suffix: ! J ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Gao J I n co Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name '' Inspected By Inspector <br /> �nQ,c,c��inA ��uvY�in <br /> Physical Address <br /> Inspection Date � O <br /> 0� �� <br /> Time In Time Out <br /> Business Rep Title 3 5 O AM 0 AM <br /> O PM � � 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 /> Q Active Q Pass@nger Q Generator Q Outdoor <br /> O ® Closed Q AltereA <br /> GPS Latitude � <br /> ot� <br /> o Q Inactive Q Truck Q HaulerQ Indo <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 n1�n <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 <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 EX) <br /> a <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 ®In Compliance-No Violations o <br /> Q Q Other:§ L <br /> Comments�n��t a uST 1 tt t UX1 <br /> �(1(gyn. <br /> o nes bti _C/-4 � <br /> �pection Form Included: Q <br /> Comments Included: Q ` ha <br /> Business Rep's Signature Phone Number Ins a tor's Signature Phone Num er <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EXAM E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop L ® ■ <br />