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Waste Tire'..>_.vey & Inspection Reps, _ Inspection Report Number ■ <br /> State of California <br /> CalRecycle I 1 - 1226239 <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- rr1� II Inspection Type(Fill one) <br /> Site Suffix: , o< c� S L O 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business orFacilityName I Inspected By Inspector <br /> Physical Address R l 0 l Cyto <br /> Inspection Date l <br /> �e�.��e r✓� C R X153310 <br /> Time In Time Out <br /> Business Rep Title �j v AM r� e *AM <br /> Q PM V `� O Q PM <br /> 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 /> * Active Q Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> Q Q Inactive Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) VVIU114 <br /> Q New Tire Dealer Q Auto Repair Q 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 /> 41P, <br /> Q Service Station Q Hauler Q Agriculture Q Shredder I* Other vi �1V1 <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 /> Q Q 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 EXE <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 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 <br /> 9-04) <br /> _ _ ) <br /> _kv�sC�LLv��c�r n <br /> Inspection Form Included: Q U <br /> Comments Included: ® - --__Phone <br /> - <br /> _ Business Rep's Ignature Phone Number Inspe or's ignature Phone Number <br /> ' 62081 <br /> INSTRUCTIONS ON BACK Correct:40 Incorrect: X E I X I AMP I L I E I I 112 3 <br /> . White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />