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Waste Tire Survey & Inspection Repo Inspection Report Number <br /> CalRecycle State of California ,_1 - 11765U7 <br /> CalRecycle l8t(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A-Surve <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: I Q I Routine Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: S(V) J 0"W 11 r WuI�__ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> d�sge� Qcr?v� �er1L_ 3 - <br /> Physical Address 1 '(� <br /> S_ � , DoCc�[J�Q _ -- <br /> S eA �S�L Inspection Date <br /> `-"`k 0 Time In Time Out <br /> Business Rep TitleO r,� ,` 0 AM 0 AM <br /> v U QPM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) t 5 5 <br /> ® Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed I* Altered GPS Latitude Q Hauler * Indoor <br /> O Q Inactive � Truck <br /> Longitude - Q Planned OTR End-Use ® 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 /> 46 Used Tire Dealer Q Auto Body Q Car Dealer 10 Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture a 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 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 Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18 (Required for NOV or EXTJ <br /> 459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q ® Q Referred/CalRecycle Enforcement <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers E <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities ---- <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:§ — <br /> Comments �-q­ i un b� t 47r- P�, i i7>�• i n r r N <br /> ___�o� �' n i u►� c�ke•J= <br /> Inspection Form Included: 1779 <br /> so-T 141 <br /> Comments Included: ®B ess R Sig tur Phone Number Inspect s Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: zX W g E X A M L 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co 4 © ■ <br />