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Waste Tire Survey & Inspeeticin H(BPOI L Inspection Report Number <br /> CalRecycle State of Californiae1Eli O 11 - 1245138 <br /> Ccyclin and <br /> Recovery <br /> vey(Ca Survey Form m Gage 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- ' _ I Inspection Type(Fill one) <br /> Site Suffix: l G� L A Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. Dc V—) Ujn Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date ( <br /> Time In Time Out <br /> Business Rep ` Title -� : Q O AM 4 ,ar 0 AM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ho / ` <br /> ' ' &Active ® Passenger • Generator •Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive ®'Truck Longitude — End Use Container <br /> Q Planned Q OTR <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 <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 � 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Datem / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle !q <br /> 12 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or Exr) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> i <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 1]„b. ,:h L U r p/?<` Q b'� (yl./Z/111 <br /> C�O Q0,JQ -At_j _f]0 <br /> '_ � 0�(� CTY QIL C�t1L� L4 <br /> Inspection Form Included: Q 7o�tQ�-L�u <br /> 2o9'-Ssq �y6�Z_ <br /> Comments included: <br /> u ess ep's Signature Phone Number spector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:I& Incorrect: � w EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />