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Jul 18 13 12: 03p p. 4 <br /> Waste Tire Survey & Inspection Repof Inspection Report Number <br /> CalReeyctDept.of 6 State of Recyclingifornia <br /> cle 1 Recovery( a1 (CalRecycle) Survey Form - Page 1 I 1 - 1210222 <br /> Part A- Survey___...._.,.. _ BLUE OR BLACK INK PEN <br /> Business Profile. Inspection Oetslls . <br /> TPID- _ Inspection Type(Fill one) <br /> Site Suffix: Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: r;. ! Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> _.._.. . <br /> Physical Address _`� v Z � '-' �'Y ;` it ice.�.L�•-E <br /> - v - Inspection Date <br /> -r . <br /> e <br /> _.. Time In Time Out <br /> Business Rep Title O AM O AM <br /> C. �_. Z.- %.... L1 19) PM �,. _ ® PM <br /> - Operational Status . :i"•irre'Iype Business Role Storage Type' <br /> Tire Count(WhoI P7E• I (Fill one only) {Fill all that apply) III all that apply) Fill afl that alziply). <br /> :� 0 Active Passenger (E) Generator Q Outdoor . <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler a Indoor <br /> O Q Inactive 10 Truck`..':.: <br /> Longitude - Q Planned CiTR Q End-Use 4 Colritalner <br /> Business Type(Fill all that apply) <br /> ......... <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ® 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 /> f <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other �: ;Y°� _ -�,k-,, ri-i: • '% <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> j V A ;HAULING AND MANIFEST REQUIREMENTS <br /> --- - -- Q <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and-Transport of Tires Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 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 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 /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462- Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations <br /> Q Q Other:§ <br /> Comments <br /> li Inspection Form Includod: <br /> I .' .=` r'� .i.. f""".._ '�"�,"', %,�r .� ,ill '"�..f' "-+ �;,r•-^'.._ .. ��-� '��,.�� ��!^-�E <br /> Comments Included: ---- -- — <br /> Bushms Rep's S6, at(irePhone Number, In i Yore K Signature _ Phons.Number . <br /> . 62081 <br /> INSTRUCTIONS ON BACK Correct Incorrect: E X Al M P L E 1 2 3 <br /> Whit.Cory CniRerv6. Yellow Copy:Operator Pink Copy:LEA <br /> 'Received Time Jul, 18. 2013 10: 53AM No. 0131 <br />