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Waste Tire S&ey & Inspection Report~ Inspection Report Number <br /> State of California <br /> CalRecycle T 1 - 1- 176478 1- 1 7 6 4 7 8 <br /> Ccyclin and <br /> (Rev.Recovery <br /> Survey Form - Page 1 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- Inspection Type(Fill one) <br /> Site Suffix: ' 3 '8 Q l *Routine Q Re-inspection Q Referral Q Observation <br /> Localr , If Referral,choose referral type(Fill one) <br /> Identifier: .J(�Y` z)C��� cc;'_ 71 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v <br /> _ Inspected By Inspector <br /> Physical Address p l 4„t�.unk,lc,� <br /> Inspection Date <br /> L�c� ro�p CA q5 Time l l <br /> Time In Time Out <br /> Business Rep Title O AM , O AM <br /> O PM pC 0 PM <br /> Operational Status Tin: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 /> ` Q Active Q Passenger ® Generator i Outdoor <br /> O <br /> GPS Latitude Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> O Q Inactive * 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 0 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 *p 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 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 O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> a <br /> Q O 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 Q1 Other:§ <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: Ifo <br /> Business Rep's re Phone Number I p ctor' gnature Phone Number <br /> �� <br /> INSTRUCTIONS ON BACK Correct:* <br /> Incorrect: (� E X I A P E 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy L ® . <br />