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Waste Tire Su. Bey & Inspection Report inspection Report Number <br /> CalRecycle State of California I 1 - 1242353 <br /> CalRecycle (Rev. (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling anddRecovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� � � 9' 6 <br /> � � � 1 Inspection Type(Fill one) <br /> Site Suffix: A Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: C^ '70 aq v�r COUP Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> \ �\e 3 `A - t O 1 N1 `�'��1 <br /> Physical Adress <br /> vEpo5 v:. <br /> �^ p Inspection Date 1 2 1 <br /> c�o <br /> O Time In Time Out <br /> Business Rep Title 1 O AM O O AM <br /> S9 PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) `T (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> `T 0 Active Q Passenger * Generator I* Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — Q Planned 0 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <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 /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other TC,22 X0.1�5 <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 <br /> 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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <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 <br /> 0 <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 /> '�C�V <br /> Inspection Form Included: Q / C� �JL�'j 7 (.� <br /> Comments Included: * �r i/,�G�Z✓t' „e 2d 1`717 —�L� L <br /> Business Rep's Signature Phone Number Inspec or's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X V EXAMPLE 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ■ <br />