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0 Waste Tire Sur Bey & Inspection Report inspection Report Number <br /> CalRecycle State of California I 1 - 1210209 <br /> CalRecycle R(Rev.y(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- Inspection 0 � _ Q t Inspection Type(Fill one) <br /> Site Suffix: Q Routine 0 Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S ��r ,(� v Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical AddressMA <br /> 1l 12uv1,_�0.-� <br /> Inspection Date - / O l / <br /> c�dor ctS 20(, <br /> Time In Time Out <br /> Business Rep Title 0�\ 0 AM 8 AM <br /> V Z � OPM � L � O QPM <br /> L,Qp2v 5 _ 7Cc�Y� p��q�iOv1 Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) n(' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> JCS 0 Active Q Passenger 40 Generator Q Outdoor <br /> O Wr <br /> GPSLatitude Q Closed Q Altered o Q Inactive 0 Truck Q Hauler Q <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 41 Trucking Fleet Q Government Q Retreader 0 Dismantler Q Tire Derived Fuel <br /> Q 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 DTbk.611A16r CotMOp C <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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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 /> Lu <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 .In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments y\ <br /> u. enc-. e ce c�ec� <br /> _ 'e a r e.0 <br /> Inspection Form Include . 0 <br /> Comments Includ d: ® 7 <br /> Busines p's Signature Phone Number Insp ctor's Signature Phone Number <br /> INSTRUCTIO ON BA Correct:& Incorrect: E X A M P L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />