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"Waste Tire S"*rey & Inspection Repor,19lnspection Report Number <br /> Cal Recycle State of California I - 1, 176732 <br /> CalRecycle (Rev. Survey Form - Page 1 <br /> Dept.of Resources Recyclingycling Recycle) <br /> and Recovery(CalRecycle) Survey <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 3 D 3 Z Z Z ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: '7 ^ , Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Nam <br /> Inspected By Inspector <br /> Physical Address <br /> 13aEr�TiFN <br /> Inspection Date l / C) <br /> Time In Time Out <br /> Business Rep Title 3 ®AM / ® AM <br /> Q PM 6 0 0 Q PM <br /> 1�_�.� �c�� cw►c� ow�'�.e-r <br /> 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 /> 9f Q Active Q Passenger Q Generator Q Outdoor <br /> GPS Latitude 0 ® Closed Q Altered <br /> Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 <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 /> Q Q 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 m / m / m <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 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 <br /> 4/im an!�1 LIU a <br /> Inspection Form Included: QIi <br /> Comments Included: ® / / C e'�' -1 ) YG�9 OwZ <br /> Business Rep's Signature Phone Number 4&pectorls Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correct: Incorrect: ; t' E X A M E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop :LE <br />