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02 Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California81( 11 - 1230303 <br /> CalRecycle 1 R(Rev.Recovery <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- Inspection i _ © � Inspection Type(Fill one) <br /> Site Suffix: ` o (� LA 18 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: s w LAI j (01A l� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> 5�Q_j n O sj� I a l <br /> Physical Address �� <br /> 3 ` l..s C07 V <br /> L � U� CA cican Inspection Date <br /> �J4 C1 J Time In Time Out <br /> Business Rep Title l 0 3 o 10 AM O PM I@ AM <br /> -L <br /> kr if/tr n U v O 0 PM <br /> - 5� 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 /> M <br /> • Active (0 Passenger 4j Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive ® Truck <br /> Longitude - 0 Planned ® OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) L <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 /> V A 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 /> PRC§42956-Registration/Decal in Vehicle <br /> 00 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 <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> CommentsLa I <br /> . �t1 A..' I <br /> n1p Vlo �N�r cs� (��- crJ�Ce.rn- <br /> S o J <br /> Inspection Form �nc <br /> ncluded: 0 - %J3 1 ' 71 3 <br /> Comments luded: • <br /> Business Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EXAMPLE 1 2 3 <br /> White Copy:C/lRecyyc Yellow Copy:Operator Pink Copy:LEA <br />