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Waste Tire Su, ✓ey & Inspection Report0lnspection Report Number <br /> CalRecycle State of California 11 - 1242256 <br /> CalRecycle 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- © Inspection Type(Fill one) <br /> Site Suffix: "� 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local r_ If Referral,choose referral type(Fill one) <br /> Identifier: �0.Y_\ � vt� �9Uh / Cl CHP_ Q_CalRecycle 0 Complaint Q Educational Visit Q Other_ <br /> Business or Facility Name Inspected By Inspector <br /> �Y�c�' �c C,,Y, �c� d h v:c cl - 1 D 1 �'� T v <br /> Physi a Address <br /> C�\ �S2 Inspection Date 1 / �7 Q' LA/ <br /> Time In 1 Time Out <br /> BusinessBusiness Rep Title 10 AM r \ U C *AM <br /> 2 Q PM 1 L ✓ 0 PM <br /> 510_V11ef2 � �� S ,rSe ;&— Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 2 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � 0 Active Q Passenger 0 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 46 Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — 0 Planned Q OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair • Trucking Fleet 0 Government Q Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer Q Collection Q 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 /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXTJ <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations <br /> O 0 Other:§ <br /> Comments <br /> `A, o`^SC� _SJ_NC in <br /> Inspection Form Included: 0 <br /> Comments Included: AL zoo IV&s2i 9 <br /> B iness Rep's Signature Phone Number Inspecto s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAMPLE 1112 3 62os1 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />