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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Cdecycle State of California 11 - 1196487 <br /> CalRecycle Recovery ev.10/10) <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> F 14-Survey BLUE OR BLACK INK PEN <br /> ass Profile Inspection Details <br /> TPID- ` ;� �✓ t !n eZ - ` Inspection Type(Fill one) <br /> Site Suffix: /� l * Routine Q Re-inspection Q Referral Q Observation <br /> Local _X'_ If Referral,choose referral type(Fill one) <br /> Identifier: C NS Q 01 Vm.V" C Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> _ ` O �, �C <br /> Physical Address <br /> ►� n M� <br /> 2G�0� fV � MC�Y� ��► <br /> Inspection Date \ 0 / (0 1 / I 3 <br /> Time In J Time Out <br /> Business Rep Title O AM O AM <br /> 1 <br /> 0 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 QPaassEinger Q Genr or Q Outdoor <br /> O Closed Q /Clte(ed N l <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> P-Riness Type(Fill all that apply) <br /> Jew 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 •Other <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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX ) <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 /> 2 <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, <br /> x•10 �`o�a\; OAA el oc �cto�o`7Comce VN <br /> Inspection Form Included: Q <br /> Comments Included: 2� l �Ob" � � <br /> Business Rep's Signature Phone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P L E 111213 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />