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Waste Tire Sovey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 11 - 1229923 <br /> CalRecycle R 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 /> Site - 1 , ` , 1 c Q Q 1 Inspection Type(Fill one) <br /> Site Suffix: `� `, –1 1 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5c N T G-o O CHP Q CalRecycle O Complaint Q Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> 6h Inspection Date <br /> ��� — \ �� Time In Time Out <br /> Business Rep Titl(e� Q AM O AM <br /> PM 4111lPM <br /> �Gh a Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) Z (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active 9 Passenger ® Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive 10 Truck <br /> Longitude – Q Planned Q OTR O End-Use O Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader O 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 O 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 /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXJ) n <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ,In Compliance-No Violations <br /> O O Other:§ <br /> Comments 2s0k-;-_Y_� �2�Q�S —�`�-' �,r�i�-�T10hy'e 'oV\ -kk�k� <br /> ��l ire< ���V�-�S�c���► <br /> Inspection Form Included: Q t, <br /> q– <br /> Comments Included: 411-Business <br /> Business Rep's ignature Phone Number Inspect is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EXAMPLEj 111_2L3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />