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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 123012-4 <br /> CalRecycle (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- 1 � � Inspection Type(Fill one) <br /> Site Suffix: ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �1 , C�u�,� If Referral,choose referral type(Fill one) <br /> Identifier: SlA� Jp( inl� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 6 Inspected By Inspector <br /> _ '1 <br /> Physical Address 3 1 10 , es co C) <br /> C� <br /> Zug Inspection Date 5 l ` / 15 <br /> Time In Time Out <br /> Business Rep Title ' O 40 <br /> �PM` I � � V � PM <br /> �►, r�► rno'��e s bvu ncI' <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> ,r�( (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> /(�J <br /> 0 Active 0 PassVn er 0 Generator 0 Outdoor <br /> O ® Closed 0 AltAre N/14 <br /> GPS Latitude 0 Hauler 01 ndo0 <br /> O Q Inactive Q Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 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 N A <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 /> 0 0 <br /> PRC§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 <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE n <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 /> W <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance-No Violations z <br /> 0 0 Other:§ <br /> Comments A i <br /> I �l � <br /> auk v1U - <br /> Cki . <br /> Inspection Form Included: 0 I Ef i <br /> / — <br /> o. <br /> Comments Included: , <br /> Business Rep's Signa u Phone Number Ins ctor's Signature Phone Uumber <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X 11 EXAM E 112 3 1 <br /> 62081 <br /> . White Copy:CalRecycle Yellow Copy:Operator Pink Co :L ® ■ <br />