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e <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of CalRecycle <br /> 81 <br /> ) 11 - 1226641 <br /> Caycling l and <br /> R Rev Recovery <br /> (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- 1 � � _ ^ � Inspection Type(Fill one) <br /> Site Suffix: 1 ! U 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: n J Q k1^ JL4A 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Narne Inspected By Inspector <br /> Physical Address W Ab <br /> go ak <br /> V � ' Inspection Date ` � / 0 <br /> 6VN TO ( A 533 <br /> Time In Time Out <br /> Business Rep Title I O AM O AM <br /> ®PM l �/ OPM <br /> -CIL �n CuAt'.nl'c,l '5�cp -FU1aMy.. -- — <br /> --- - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 5 <br /> ®Active 0 Passenger ® Generator Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> 0 0 Inactive ® Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use ® Container <br /> Business Type(Fill all that apply) _ <br /> 0 New Tire Dealer 0 Auto Repair ® Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> a <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <br /> W <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities -_- <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 0 Other:§ <br /> j, <br /> CommentsA)UG 'j c,1 ['10-1 f1 <br /> on viol of)s oI izL _ ern _ <br /> Inspection Form Included: 0 J <br /> Comments Included: ® �� <br /> Business Rep's Signature Phone Number Insp or-s Signature Phone Number <br /> E X A M 1 2 3 62081 <br /> ■ INSTRUCTIONS ON BACK Correct: Incorrect: © ■ <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L <br />