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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1245364 <br /> CalRecycle 187(Rev.y(Cal Survey Form - Page 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- O� Inspection Type(Fill one) <br /> Site Suffix: _ eRoutine QRe-ins Re-inspection <br /> Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: C,� L , QCHP QCalRecycle <br /> Q Complaint Q Educational Visit Q Other7t,)* <br /> Business or Facility Name - <br /> Inspected By Inspector <br /> v�>C �c Q 1 <br /> Physical Address <br /> S <br /> �s2� t <br /> Inspection Date O / Q 3 / 1 5 <br /> Time In Time Out <br /> Business Rep (� C Title 1 2 Q AM 0 AM <br /> 1 PM Z � I 0 PM <br /> t" e Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Q Passenger i Generator • Outdoor <br /> GPS Latitude 0Q Closed Q Altered I <br /> Q Hauler Q Indoor <br /> Longitude <br /> 0 Q Inactive . Truck <br /> - End-Use <br /> • Q Planned Q OTR Q 0 Container <br /> Business Type(Fill all that apply) - <br /> Q New Tire Dealer Q Auto Repair 9 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires -- ONotice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle m <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle III rrr III`�T" <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years N <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> X <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 z <br /> Q In Compliance-No Violations <br /> Q Q Other:§ o <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: — —coq-a33L c ` <br /> Bu ' P.-ss Rep's Si nature Phone Number Inspec is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: M � g E I X A M P I L E 1 2 3 1 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA . <br />