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Waste Tire Su. Bey & Inspection Repori inspection Report Number <br /> CalRecycle <br /> State ofCelifornR I1 - 12 2 9 9 61 <br /> CalRecycle cover (CalRecycle) Survey <br /> Survey Form - Page 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 0 Inspection Type(Fill one) <br /> Site Suffix: l 1 • Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5cii,� O" Co W V� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business <br /> yo�r Facility Name Inspected By Inspector <br /> Phy `Inn es ` <br /> Inspection Date � 2 � S <br /> -V'v-r_y" . C,t�v CP\ 915231 <br /> Time In Time Out <br /> Business Rep 1 _, Title I ` � � 0 AM ` O AM <br /> O PM I' Z � C3 QPM <br /> S 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 /> 9 Active 0 Passenger • Generator 0 Outdoor <br /> GPS Latitude <br /> O 0 Closed 0 Altered <br /> Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE c? <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 2 <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators %In Compliance-No Violations o <br /> 0 1 0 1 Other:§ <br /> Comments9-0 l InR <br /> Inspection Form Included: 0 <br /> Comments Included: W19-3 <br /> Business Rep's Signature Phone Number Inspect or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:I. Incorrect: X4 NJ EIXIAIMIP I LJEJ 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />