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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle state of California 11 - 1210420 <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 PE_N <br /> Business Profile Inspection Details <br /> TPID- � Q � � � © I �Inspection Type(Fill one) <br /> Site Suffix: 4D Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ( JQ U/111% Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> (�(� Co L <br /> / Inspected By Inspector <br /> 1 16�5�1 C\ �jSO ocf' W- , LC /��T <br /> Physical Address 3 - Q l �W 1 T <br /> - <br /> Inspection Date � / Q <br /> IS��S Q / 1 <br /> C Time In Time Out l <br /> Business Rep ` Title (� rl O AM Q AM <br /> v ®....PM ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> If Active Q Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GP� Latitude Q Hauler 0 Indoor <br /> O Q Inactive I& Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q 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 /> 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 /> QQ 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 a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or Ex7) N <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 O 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 1 Q 1 Other:§ <br /> z <br /> Comments N <br /> �n n ' <br /> 00 y i 06/ cv,s n ) (A fat � �� since n <br /> Inspection Form Included: Q <br /> Comments Included: - - - � <br /> Buskesss p's Signature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: M � q E X A M P L 1 111 <br /> 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy. © ■ <br />