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0 Waste Tire Soey & Inspection Repor Inspection Report Number <br /> CalRecycle State of California <br /> 10/10)CalRecycle I 1 - 1226288 <br /> Dept.of Resources Recycling and Reco ery(CalRecycle) Survey Form - Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Q Inspection Type(Fill one) <br /> Site Suffix: ` S / L( 0 ( ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. w Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �cvrtJtI e„ 37 <br /> 22 <br /> Physical Address 1 — ! Q f � <br /> Inspection Date <br /> C14 3 U <br /> Time In Time Out <br /> Business Rep Title C— ®AM O AM <br /> 1 l J Q PM ! C- O ® PM <br /> '( LStLri'Ii /n�r Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) j (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> (p ® Active ® Passenger ® Generator ® Outdoor <br /> o Q Closed Q Altered <br /> GPS Latitude Q Hauler ® 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 /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader ® 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 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 Notice Of Violation 0 Extension <br /> - - —-- - <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 /> QQ 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 N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> r <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 <br /> Q 1 Q Other:§ <br /> Comments - <br /> IAJokr ked <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Bus' s nature Phone Number Inspector's Signat a Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: M � EXAM E 112 1 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: <br />