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Waste Tire S 31y & Inspection Repor , spection Report Number ■ <br /> State of California <br /> CalRecycle I 1 - 1176545 <br /> CalRecycle and <br /> (Rev.Recovery <br /> 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- Inspection Type(Fill one) <br /> Site Suffix: ' S 4 o '� tG' 0 ' IbRoutine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ,J V <br /> / Inspected By Inspector <br /> / <br /> / w'�C Ac& <br /> Physical Address �/ <br /> J_ Inspection Date U A / 01r4 �S_30 / <br /> Time In Time Out <br /> Businessep Title O ! 4 S O AM Q3 O AM <br /> ®PM ® PM <br /> -- <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 /> ®Active 0 Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer ® Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer ID 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 A HAULING AND MANIFEST REQUIREMENTS <br /> - — - -- --- -— - Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline i <br /> Q Q 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 /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Requiredfior NOV or EX7) N <br /> O ® 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 /> I � <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 /> O Q Other:§ — <br /> Comments <br /> - <br /> Inspection FormIncluded: Q x <br /> Comments Included: ® - <br /> Bu ss Rep's SignaturePhone Number spector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct. Incorrect: 62081 <br /> EXAM L 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop L <br />