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Waste Tire Su. rey & Inspection Report inspection Report Number ■ <br /> CalRecycle State of CalRecycle <br /> 181(R I 1 - 1210367 <br /> Caycling let8l(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- 1 I © - © Inspection Type(Fill one) <br /> Site Suffix: b 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local r--� 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 Inspected By Inspector <br /> CAq Norco <br /> Physical Address -I�y <br /> - c) ATT <br /> ftvie- <br /> - -- <br /> Inspection Date S / 3 Q 3 <br /> C�ckp �f� t�S2� Time In Time Out <br /> Business Rep n (�- Title 0 AM *AM <br /> / � <br /> 1 )�eaN\CI, !'ZI0. , mw)a J 0 PM 1 Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 3 Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 40 Active • Passenger Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned 0 OTR 0 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 A 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 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 <br /> 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 9 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> 6.1 <br /> Q Q 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 /> 2 <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 Q Other:§ 1� 1A. AA— {{AA <br /> Comments �kih2. W"k 'tir2. i�Sp�c � Aon" CSV, �"S A:it-k <br /> ' 0W->L. tY`Q rWC�S hn " <br /> 04 <br /> Inspection Form Included: Q <br /> Comments Included: � " qV3 - 3U Zoci-` 68--.?7_ <br /> Business Rep's Signature Phone Number Inspec is Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:0 Incorrect: V �jEjXjAjMjPjLjEj 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />