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Waste Tire S§Vey & Inspection Repor ,, Inspection Report Number <br /> CalRecycle State of California I 1 - 1230122 <br /> CalRecycle 181 lleco v ry(Ca) 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- n O - O Inspection Type(Fill one) <br /> Site Suffix: "� , • Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local \ .1 If Referral,choose referral type(Fill one) <br /> Identifier: �>n<QU� \r% UrN 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> C M �\ <br /> Physical Address <br /> C� rls 71( <br /> Inspection Date_1 J <br /> Time In Time Out <br /> Business Rep Title !� 0 AM C' ®AM <br /> Cj�,\Q C�GPi Q-AcAn� i`1 �. U U 0 PM I I J O PM <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 /> � <br /> ®Active 0 Passenger • Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned ® OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 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 (c� <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 /> 0 0 PR § - 0 Notice Of Violation 0 Extension <br /> C 42951 Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 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 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE A <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 /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> 0 1* 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> e In Compliance-No Violations o <br /> 0 0 Others§ - <br /> Comments <br /> is AeJ.- <br /> se'g' (�rc�Q.��S C <br /> Inspection Form Included: 0 1 ^ ,ry r J/�M 1 1 <br /> Comments Included: 0 %(J S/ J ' <br /> Bu s e Signature Phone Number Ins tor's Signat a Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EXAM El 111213362081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop L <br />