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Waste Tire Su, vey & Inspection Repon Inspection Report Number <br /> CalRecycle State of CalRecycle <br /> (Rev. <br /> R I 1 - 1245145 <br /> Ccyclin and R.(Rev.1 (CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �` Inspection Type(Fill one) <br /> Site Suffix: 7 O � (� V S Routine Q Re-inspection Q Referral Q Observation <br /> Local Al" If Referral,choose referral type(Fill one) <br /> Identifier: J b"` !���� ��� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date 1 � / (:> 1 / is <br /> Time In Time Out <br /> Business Rep Title -- `` � c O AM 7 O AM <br /> Qi�'G�r - J 0 PM d G e PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) a (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 4P Active 0 Passenger e Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> C Q Inactive 0 Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q 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 <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 EXE N <br /> 0 <br /> 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:§ <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspect 's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X4V]jEjXjAjMjPjLjEj 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © 0 <br />