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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1196420 <br /> CalRecycle R(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- Q Inspection Type(Fill one) <br /> Site Suffix: 1 b J 3 , �[ (J '� ® Routine Q Re-inspection Q Referral Q Observation <br /> Local \ �U If Referral,choose referral type(Fill one) <br /> a <br /> Identifier: `l �� (—G Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Businessor Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date I / O / t <br /> C— Time <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0P Q ePM <br /> G G ✓Y(7� — �Lt/�G` 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 I& Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer fj 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 I 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 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 Q Referred/CalRecycle Enforcement <br /> 20 <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators &In Compliance-No Violations <br /> Q Q Other:§ <br /> 6 <br /> Comments <br /> Inspection Form Included: Q OGZ <br /> Comments Included: <br /> Business Rep's Sign re Phone Number I s is tignature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A 62081 <br /> P L E 1 2 3 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Co <br /> C.L ® ■ <br />