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Waste Tire Sup Bey & Inspection Report inspection Report Number <br /> CalRecycle State of California I 1 1230251 <br /> CalRecycle (Rev. (CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling anddRecovery(CalRecycle) <br /> tart A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ^ Inspection Type(Fill one) <br /> Site Suffix: L 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: �� Ce �V."� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> 5-3% Time <br /> Date I -,7 <br /> Time In Time Out <br /> Business Rep Title ® 6 AM 1 *AM <br /> Q PM 0 PM <br /> V-CX�SA� �Q'1Operational Status Tire Type Business Role Storage Type <br /> / 1 <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger J9 Generator I* Outdoor <br /> Q Closed Q Altered <br /> �PS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — Q Planned 40 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 AS i;�6iss kV-\e--S5 <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> IQ 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 /> f <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 /> QQOther: <br /> § _ <br /> z <br /> Comments 90.$ _ �c2 <br /> �, iIZAs3L�"'00S ar �CpcAS O'� CZ_►_1C P-r✓1 <br /> Inspection Form Included: Q <br /> Comments Included: _ 5'- (ty — __2 <br /> ? <br /> Business Rep's Signature hone Number lnsp or's ignature Phone Number <br /> INSTRUCTIONS ON BACK <br /> Correct: Incorrect: X/ � VE X A M P L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA �� ■ <br />