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Waste Tire Su Jey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1230125 <br /> CalRecycle (Rev.Recovery <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- ` V) _ Inspection Type(Fill one) <br /> Site Suffix: 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: 5�n 10CA-A 1A)^ 60u'-) 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name1 Inspected By Inspector <br /> Physical Address 10 ES/ -rto <br /> Inspection Date s / I G / 15 <br /> `1 Time In Time Out l <br /> Business Rep Title O AM ® AM <br /> ' l V QPM ` 1 "l � QPM <br /> P--uC�h�.k V N1 I a��n &5 b w�� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) it 3 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J 0 Active ® Passenger 0 Generator ® Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O 0 Inactive ® Truck <br /> Longitude - 0 Planned ® 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 (7(Ct9P, 1A6tf Nt3kln <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 /> 0 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 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 EXTJ <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <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 0 Other:§ <br /> Comments Ar <br /> `lam N <br /> Inspection Form Included: 0 <br /> Comments Included: ® <br /> Business Rep's Signature Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X �� E X A M P L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />