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Waste Tire shy & Inspection Repor'00spection Report Number <br /> CalRecycle State of California I 1 - 1176510 <br /> Ccyclin cletfRecov(Rev.Recovery <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey B_L_U_E OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` - Q Inspection Type(Fill one) <br /> Site Suffix: 4 y * Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: CLv1 `fN Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical <br /> I `lddre'ss <br /> ,&CJ< L• n f�C 3 <br /> C+ <br /> Inspection Date <br /> CA' 1572N- <br /> Time In Time Out <br /> Business Rep Title ® AM AM <br /> QPM ` ! 3 � QPM <br /> - <br /> �J 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 /> > > <br /> Active Q Passenger ® Generator ® Outdoor <br /> Closed <br /> Latitude 0 Q Altered <br /> GPS ------- Q Hauler Q-Indoor.--- <br /> 0 Q Inactive ® Truck <br /> LongitudeQ Planned Q OTR <br /> - End-Use Container <br /> • <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> -- <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 /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date ED m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years U) <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q O 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 /> I If <br /> Inspection Form Included: Q x f <br /> Comments Included: � — �•' <br /> Bus' ss Rep's ignature P one Number nspector's Signature Phone Number <br /> INSTRUCTIONS ON BA K Correct: Incorrect: Xj E X A E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink C � <br />