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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1196484 <br /> CalRecycle (Rev.Recovery <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> A-Survey BLUE OR BLACK INK PEN <br /> ess Profile Inspection Details <br /> TPID- � � � � � /y 9 Inspection Type(Fill one) <br /> Site Suffix: b ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: !1 <br /> ��� JOQ�V b� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical AAddress e s - 1 © � 1v1 `�'Tv <br /> d <br /> Inspection Date C) <br /> Time In Time Out <br /> Business Rep Title I 0 AMj O AM <br /> Z PM ' J 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 0 Passenger Q Generator O Outdoor <br /> O 0 Closed Q Altered <br /> GPS Latitude <br /> O Q Inactive 0 Truck Q Hauler Q Indoor <br /> Longitude - Q Planned O OTR O End-Use Q Container <br /> Rlisiness 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 /> U Used Tire Dealer Q Auto Body Q Car Dealer 0 Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder I* 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 /> O O <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 /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> O Q Other:§ <br /> Comments, �� �!• Yee✓ ��9CYS� \� fit.. �.���„\ <br /> Mn <br /> utspection Form Included: Q <br /> Comments Included: ® ---' <br /> Business Reps Signature Phone Number Inspec or,s Signature Phone Number <br /> �-,( <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: N NJ EXAMPLE 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © 0 <br />