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Waste Tire Arvey & Ins ection Re o Inspection Report NumberCafRec cle State of Ga�I�la A Rep <br /> or? <br /> CalRecycle 181 tRev.,a,e► I1 - 123012 0 <br /> Dept or Resources Recycling and Recovery(C°IRecycb) Survey Form --Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- J� l Inspection Type(Fill one) <br /> Site Suffix: I_7LiJs , Lzb4l iJ 1 (a Routine Q Re-inspection Q Referral Q Observation <br /> Localt If Referral,choose referral type(Fill one) <br /> Identifler. L-5-4nioa vtiln �� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address I f✓ ] i 6J&oTr6 <br /> L --- <br /> Street <br /> IS-LOSInspection Date I [ S <br /> C,ty tate Z!P Code Time In Time Out <br /> Business Rep i Title 0 AM 0 AM <br /> [a O O a PM El� ' U0 M <br /> Operational Status Tire Type Business Role Storage Type <br /> lire Count hole/PTE (Fill one only) (Fill all that apply) (FII all that apply) (Fill all that apply) <br /> Q Active Q <br /> Passe <br /> nger Q Genera <br /> tor Q Outdoor <br /> O * Closed Q / <br /> GPS Latitude 10 Q Inactive Q Truck <br /> QHa!ArQ or <br /> Longitude Q <br /> Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q 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 LNI <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I 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[]] <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 EX7) <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 <br /> Q O 14 CCR§18462- Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance No Violations o <br /> Q Q Other: <br /> Comments t , , 1 t <br /> v )�s �o lliQ ,��rs�f. s_a�ctj�u�• .� <br /> i_AQt0^hCJ"-ie%tr ' tA� �i��1�?, �+I-;_ IS Gln Q m"+M �l? <br /> Inspection Form Included: Q <br /> Comments lnciuded: Q -- _ <br /> Phone Number -Inw� �{Phone NumberBusiness Rep's Signature - <br /> INSTRUCTIONS ON BACK Cort: In ect: xx � q s2oe1 <br /> EXAMPLE 1 2 3 <br /> White Copy: alRe a Yellow Copy:Operator Pink Copy:LEA <br />