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Waste Tire Su, vey & Inspection Repor , Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1242313 <br /> Ccyclin and R cover (Cal 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- " <br /> , � � � "] � Q Inspection Type(Fill one) <br /> Site Suffix: `1 ` f ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �- t r If Referral,choose referral type(Fill one) <br /> Identifier: �{�Jo 0_1 1A 11 n Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ° Inspected By Inspector <br /> Physical Address Q <br /> Inspection Date 9 <br /> Time In Time Out <br /> Business Rep 1 2 TittllCel O AM lO AM <br /> SPM t � 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 /> 0 Active ® Passenger ® Generator ® Outdoor <br /> GPS Latitude 0 Closed Q Altered <br /> Q Hauler Q 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 /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 1 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 <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 / 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 /> 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 49 In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments 4'rV v 1 r` �v t ���Ll l'L CJla7(� —1 1' t771� <br /> N v "J n LlS (A Iu'&� <br /> Inspection Form Included: Q <br /> Comments Included: ® �p�` l�' <br /> Business Rep s Signature Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X E I X I AMP E 1 -2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy LE <br />