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Oa Waste Tire Sur Bey & Inspection Report ispection Report Number ■ <br /> CalRecycle State of California I 1 - 1226327 <br /> CalRecycle t6l(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> - — BLUE OR BLACK INK PEN <br /> Sart A- Survey_ <br /> Business Profile Inspection Details <br /> TPID- h Inspection Type(Fill one) <br /> Site Suffix: V '-7 ( 'O Routine Q Re-inspection Q Referral Q Observation <br /> Locala If Referral,choose referral type(Fill one) <br /> Identifier: �PJ1�1-j0 kj IA'1'\ C` 1A Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ar , - 1 <br /> Physical Address 3 a <br /> � ��� Inspection Date � 5 / I <br /> VV J Time In 1 Time Out <br /> Business Rep Title I AM a � U O AM <br /> t� QPM OPM <br /> Ck Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) Q <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q ® Active 0 Passenger 0 Generator ® Outdoor <br /> O Q Closed 40 Altered GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned ® 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 * 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 18459.2.1 <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 /> 2 <br /> Lu <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 /> Q Q Other:§ <br /> Comments �� und <br /> N V14)w41 VA I ci1 u 1C-,A (T7 '/0—ilo-rP, --- - <br /> Inspection Form Included: <br /> Comments Included: - - - t'^�`w!�-/!3 6Z-� U <br /> usi ess Rep's Signatu a Phone Number Insp or's Signature Phone Number <br /> --- — - � J E X A M P L E 1112131 <br /> 62os1 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: I X <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ■ <br />