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Waste Tire Survey & Inspection Report inspection Report Number ■ <br /> CalRecycle State of California 11 - 1196529 <br /> CalRecycle 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 o - ,oma Inspection Type(Fill one) <br /> Site Suffix: (� . Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �Q,� ��/�[1 v,Y., �V V�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physi�c d-ess � <br /> Inspection Date <br /> `` Time In Time Out <br /> Business Rep / Tittlle` O AM c O AM <br /> • PM I J � 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> 7 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active Q Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q 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 • 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 <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 <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 /> Inspection Form Included: 0-- (700 -20Z'410 <br /> Ak's -� 2ocj"4VS��oIComments Included: -- -- <br /> usiness Rep's Signat a Phone Number Ingnature Phone Number <br /> �( 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X �J E X A M P L E l 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />