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r <br /> Waste Tire Su, Bey & Inspection Report inspection Report Number <br /> CalRecycle State of CaliforniaCalRecycle 11 .- 1196470 <br /> Dept of Resources Recycling and BR Recovery very(CalRecycle) Survey Form - Page 1 <br /> P - A-Survey BLUE OR BLACK INK PEN <br /> ess Profile Inspection Details <br /> TeiO- v 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: < a0G_Cl V`� cG�� / Q CHP Q CalRecycle 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> ( Q Inspection Date 4 c) / 1 S / ` 3 <br /> Acaw,eo C- Ise za 4 <br /> Time In Time Out <br /> Business Rep Title c C $ AM 1 AM <br /> O J J Q PM I 1 ` 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 /> ' ' 16 Q Active Q Passenger Q Generator Q Outdoor <br /> O 10 Closed Q Altered <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 /> Business Type(Fill all that apply) <br /> ew Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> V Jsed 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 <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 /> Q Q 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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> _ a <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 Generatorsle In Compliance-No Violations o <br /> Q Q Other:§ <br /> z <br /> Comments ` <br /> q. Ohm �S &0t p_ 0.N <br /> pL�� a�:d�5 oCCP cS c421 ��ncec <br /> �_pection Form Included: Q V6 C-3 C / <br /> Comments Included: 0 <br /> 17� <br /> Business Rep's Signature Phone Number Insp ctor s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:I* Incorrect: EXAMPLEI 1112L3] 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />