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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Cal Recycle State of California 11 - 1230236 <br /> CalRecycle d.Recovey(Ca) Survey Form —Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Sart A-Surv_ey __ _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` � � ' � � � _ © � Inspection Type(Fill one) <br /> Site Suffix: ` 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local � ` If Referral,choose referral type(Fill one) <br /> Identifier: SQA, �OCt j V ti V_",V_", ^W 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ` 'rr Inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AM <br /> 0 AM1 <br /> 0 PM l.J `PM <br /> - � Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> TE 1 ?j <br /> Active 4D Passenger a Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 40 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 0 PR - 0 Notice Of Violation 0 Extension <br /> C§42951 Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle A <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> a <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> Lu <br /> Lu <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •in Compliance-No Violations o <br /> 0 0 Other:§-m t�rkt _ <br /> Comments 17 Q 1 Ub.St� �t trP �v�c Eew c�oV� �r -eAcok <br /> NV 2- {p\\p WN U.9 CIrS Y1 O P/7 <br /> I <br /> Inspection Form Included: 0 <br /> Comments Included: ® <br /> VR ,P's Si nature Phone Number Inspe tor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P L 1 E I 1112 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA G� ■ <br />