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OZ Waste Tire Su. ✓ey & Inspection Repori _ Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1242259 <br /> CalRecycle (Rev. y(Co) 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- ® � � � � - O I Inspection Type(Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: TomkD%� OA Q CHP Q CalRecycle0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` Inspected By Inspector <br /> s�ea�c A\ .�y <br /> Physical Address <br /> ch 01,526 Inspection Date / 30 <br /> I <br /> Time In Time Out <br /> Business Rep Title AM AM <br /> Q PM ® O PM <br /> soxo2Cic V�1"n�� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 9 'J (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger 0 Generator • Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 18 Truck <br /> Longitude - Q Planned Q OTR Q End-Use • Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 /> 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 EX>) N <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 - —cA,�-t o yx cs't-\ <br /> �ce ol.�S LV.Ls beer Csncc� <br /> (-,C- �S (:0v\C_CJ\ <br /> Inspection Form Included: Q <br /> Comments Included: 4D <br /> tines <br /> p's S nature Phone Number. Insp Ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAMPLE1 1112L3] 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />