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Waste Tire Su. vey & Inspection Report spection Report Number <br /> CalRecycle State of cle 181(R I 1 - 11 -17994 <br /> Ccyclin and <br /> (Rev.WHO) Survey Form - Page `� <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: C) g- 'g— - l Q Routine Q Re-inspection Q Referral I&Observation <br /> LocalL - If Referral,choose referral type(Fill one) <br /> Identifier: �'� � ��` ����, �/ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 <br /> Inspected By Inspector <br /> Physical Address <br /> Inspection Date 6 / / 1 Z - <br /> 7 <br /> Time In Time Out 1 G <br /> Business Rep ,^ 1l�A \ Title 0 AM Q AM <br /> Jc�v 1 <br /> Y 1� 16C,_ D V ® PM 3 3 v o 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 /> ® Active 41,Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude ® Hauler Q Indoor <br /> O Q inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End-Use 49 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 (1111 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 /> 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 M.�zo / 51�, <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years N <br /> 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 Q In Compliance-No Violations o <br /> Q Q1 Other:§ <br /> ---- z <br /> Comments <br /> u <br /> Inspection Form Included: Q <br /> Comments Included: ® 3 "a0l"05 76 <br /> Business ep's Signature Phone Number Ins ec is g re Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A M P E 1 11 1213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pi LEA ® 0 <br />