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Waste Tire SL.. iey & Inspection Report inspection Report Number <br /> CalRecycle State of California I 1 - 1229936 <br /> CalRecycle .R Recovery(Rev.y(CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept of Resources Recycling and Recove (CalRecycle) <br /> Part A-Survey_ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' 2I 3 3: _ Inspection Type(Fill one) <br /> Site Suffix: I* Routine Q Re-inspection Q Referral O Observation <br /> Localrt If Referral,choose referral type(Fill one) <br /> Identifier: 5 G h Jb O-q V'm Cc�Vw Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address, C 39 I O I MATT v <br /> Ilq o S�cQc��S �• - <br /> �� � <br /> \"eC0.- � ����� Inspection Date b 2 / /� 6 <br /> h / <br /> Time In Time Out <br /> Business Rep t Title [— 0 AM O *AM <br /> 7�V� ��Yl1n•+2�1 r�,2:2T M,2�4h� QPM 1 "1 � PM <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 /> 0 J* Active 0 Passenger 40 Generator 9 Outdoor-] <br /> O Q Closed O Altered <br /> GPS Latitude 0 Hauler * IndoorZ <br /> O Q Inactive * Truck <br /> Longitude - End-Use Container <br /> Q Planned O OTR <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 40 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 /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle A <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations <br /> O O Other:§ <br /> Comments <br /> Inspection Form Included: Q c <br /> Comments Included: <br /> Business Rep's Signature Phone Number nspect is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A M P L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © 0 <br />