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Waste Tire S6, rey & Inspection Report 4nspection Report Number <br /> CalRecycle State of CalRecycle <br /> 11 - 1196506 <br /> Ccyclin andR(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- � � � (� _ © 1 Inspection Type(Fill one) <br /> Site Suffix: I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local \ If Referral,choose referral type(Fill one) <br /> Identifier: sQl� �OG�Q U�� �t�Y�` 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 4 / Inspected By Inspector <br /> I Physicaddress <br /> 3 oS <br /> Inspection Date 9 / q / <br /> Time In Time Out <br /> Business Rep Title C 0 AM 9 C AM <br /> ✓ 0 PM F J 0 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 /> (rQ 0 Active 0 Passenger ® Generator 0 Outdoor <br /> O 0 Closed 0 Altered N l <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair • 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 EXT) n <br /> 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance No Violations o <br /> 0 1 0 1 Other:§ <br /> Comments <br /> Inspection Form Included: 0A- lhfaed o 32 <br /> / <br /> Comments Included: <br /> iusiness Rep's Sigrnture �hene Numwer Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X IEIXIAIMIPILIEI 1112 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />