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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of CalRecycle <br /> California 11 - 1242330 <br /> Ccyclin andR(Rev.Recovery <br /> Survey Form - Page 1 <br /> 0110) <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 n _ O Inspection Type(Fill one) <br /> Site Suffix: ") ® Routine Q Re-inspection Q Referral Q Observation <br /> Locale If Referral,choose referral type(Fill one) <br /> Identifier: Sala J OLtLI ul r� un Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l <br /> Inspected By Inspector <br /> A c(o w -Tcjc,tz_ C'J� , _ f o J Est✓flT?� <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep TitleO AM O AM <br /> Q <br /> U ® PM 5 ® PM <br /> Operational Status Tire 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 /> ' 16 e Active Q Passenger • Generator Q Outdoor <br /> o Q Closed Q Altered PIA <br /> GPS Latitude 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 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 <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 Q �Notice Of Violation Q Extension <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 N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <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 1 Q 1 Other:§ <br /> Comments 1 511 <br /> G lx�n�1 <br /> wmp now <br /> Inspection Form Included: Q <br /> Comments Included: w� <br /> siness ep's Signatu Phone Number Insp is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: orrect: E X A M L 1 2 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink C py L ® ■ <br />