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In:_,,;;ction Report Number <br /> Waste Tires Su, ve,, & Inspection Re�jr� � <br /> CalRecycle State of California 11 - 1226224 <br /> CalRecyclei8l(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> BLUE DR BLACK INK PEN <br /> PartA-Surve <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: ) Q (p (� 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Soo\ �O "1� Ca-'�'�h-� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 11'C(J <br /> Physical Address's v, l Q1�- <br /> 3 <br /> C <br /> (� �} Inspection Date f / / C 7 <br /> `� g5RO S Time In Time Out <br /> Business Rep Title <br /> ` �C 0 AM J AM <br /> 6 J <br /> I • ® PM • -3 5S Ai PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 7 t (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> X 1 0 Active Q Passenger 0 Generator Q Outdoor <br /> Q Closed Q Altered <br /> Latitude <br /> GFS Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use ® Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m m m N <br /> Q 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q 0 14 CCR§18 - (Required for NOV or EX77 N <br /> 459.2.1 Submittal of Comprehensive Trip Logs within 90 days <br /> Q 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> w <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Q Q Other:§ .- <br /> Comments <br /> gS e N <br /> Inspection Form Included: Q <br /> Comments Included: ® <br /> Bu m er 1 p cfor' Si nature Phone Number <br /> Rep's ignature Phone Nu <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: I rrect: � EXAMPLE 1 2 3 <br /> ■ White Copy:CalRe cl Yellow Copy:Operator Pink Copy:LEA E;i ■ <br />