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e • } :•-:: : -: :. �.r�.r.� - -- --- --- <br /> .Y}z rl�em/e°dGls�:.LG.�n/Y..d k.:.,,.r..rrr •+r....,.�.. .._.. .....-.._ .. _ <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 - 12 2 6 6 8 7 <br /> CalRecycle (Rev. y(Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A - Survey_____ ----- -- - - <br /> Business Profile Inspection Details <br /> --. - <br /> TPID- / Inspection Type(Fill one) <br /> Site Suffix: Q '1 V C) a Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ` i`n �CGC�� �t� C`J�' Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address l C) <br /> / e15-74 <br /> iJ�4 6 <br /> A }C Inspection Date <br /> `� Time In Time Out 10 <br /> AM AM <br /> Business Rep Title i t y O PM ( 0 PM <br /> 0A 11` Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 3 IS Q) Active Q Passenger ® Generator 40 Outdoor <br /> PS Latitude Q Closed Q Altered Q Hauler Q Indoor <br /> G <br /> O Q Inactive ® 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 ® 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 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 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 m m N <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle � <br /> (Required for NOV or EX7) N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days a <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 <br /> 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: Q00" <br /> Comments Included: Business 000 <br /> Re s Igna�lure _Phone Number 4Copy <br /> e Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect: v� 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator ® ■ <br /> ■ <br />