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Waste Tire Su. ✓ey & Inspection Reporonspection Report Number <br /> Cal Rec cle State of California - 1242258 Y CalRecycle 141(Rev.10/10) Survey Form - Page 1 I1 12 4 2 2 5 8 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- inspection� O O 1 - O ` Inspection Type(Fill one) <br /> O <br /> Site Suffix: ` 1 O Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: V� _ Q CHP._.___Q_CalRecycle Q Com laip nt Q Educational Visit_ Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> vl�\1 �les� Lv�• , t <br /> C� Q$210 Inspection Date O <br /> Time In Time Out t <br /> Business Rep Title O AM 2 O AM <br /> 0 PM 2 a PM <br /> 70.v1n \� ©W�ne <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(VNhol PT (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 9 Active ! Passenger ! Generator Q 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 0 Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 0 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 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 /> 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 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement t <br /> Lu <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 o <br /> 010 Other:§ <br /> Comments <br /> W� W <br /> Gv kcpaS Irov%cccn S <br /> Inspection Form Included: Q �,,,�/ t`/p. *� <br /> Qe)/l.1 7�' U � lJ�TI"'G W'W <br /> Comments Included: <br /> Busi Rep's Signature Phone Number Insp ctor's Signature Phone Number <br /> �-�{ <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X 4 �J E X A M P L E 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />