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2 Waste Tire S&A \gay & Inspection Report Inspection Report Number <br /> CalRecycle State of California 6� W� — R ^ <br /> CalRecycle 1$1(Rev.y(CalRecycle) Survey <br /> `urvey Fort 1� - Page 1 1 1 '2 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) V � 1/ <br /> 42127 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: Q Ca -T CL 4- l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local r L ��- If Referral,choose referral type(Fill one) <br /> Identifier: ](•l Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Addres <br /> Inspection Date S? / ' <br /> f rr � C q 537 �J Z <br /> Time In Time Out <br /> Business Rep Title ®AM ) _ ®AM <br /> \\,^ / I0 • 5 6 Q PM ( � OZ S Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � (� <br /> ® Active ® Passenger a Generator Q Outdoor <br /> G O PS Latitude Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use ®Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer I& Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 EXE <br /> 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 1 Q 1Other:§ <br /> - - z <br /> Comments <br /> Sc — <br /> 60/1/ <br /> Inspection Form Included: O _ 2- O 7 - 9 y 2 Vne <br /> Comments Included: ® Business Rep's Signature Phone Number or's/gnre Phone Number <br /> • 62081 <br /> .INSTRUCTIONS ON BACK Correct: Incorrect: V7 EXAM 1 1213] <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop L ® ■ <br />