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Waste Tire Survey & Inspection Repord Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1245139 <br /> CalRecycle 161(Rev.y(CalRecycle) Survey <br /> Survey Form - Page 1� <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I j Z - ( Inspection Type(Fill one) <br /> Site Suffix: ` I a Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: Y-1 SCQL7'r1 co-c_-'�A Q CHP Q CalRecyde Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address I 1 I �� 1 V A-L' <br /> LcaL <br /> Inspection Date I / 3 / l <br /> Time In Time Out <br /> Rep <br /> Business Re Title O AM Z AM <br /> © S PM O a PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> re C <br /> Tiountl( of /PTE) j/ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active S Passenger ® Generator ® Outdoor <br /> 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 Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body • 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 <br /> 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 / 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 (Required for NOV or EXT) N <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance No Violations o <br /> Q Q Other:§ ///� <br /> + ,� 0K�v CA, J.1 <br /> Comments��•� , "� G�� 1,`.� �W <br /> AJO <br /> Inspection Form Included: Q ,Alk 91)j 114" 76ol 4&f—z 8 3� <br /> Comments Included: <br /> Tw— <br /> Bu es ep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON CK 6rrectq Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />