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Waste Tire Survey Mss clUan Repot L ' Inspection Report Number <br /> State of California <br /> CalRecycle calRecycle 101(Rev.10/10) Suv JForm page 1 I1 - 1245140 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � ✓L /�, ,r/� � _ � I Inspection Type(Fill one) <br /> o 5-Site Suffix: i+ —j J 0 Routine Q Re-inspection Q Referral Q Observation <br /> Localr If Referral,choose referral type(Fill one) <br /> Identifier: �� 3 Ca u Cc Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �Y rn a-2. � / o <br /> Physical Address � ��� ` <br /> o <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title j O AML, AM <br /> I A PM �' ✓ d PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count( ,h le/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> l!G 40 Active `'Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> ��� latitude Q Hauler o 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 I A I 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 <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 Exr) 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 /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators o In Compliance-No Violations o <br /> Q Q Other:§ <br /> CommentsU — <br /> _ <br /> No yr ce� y alLLoo <br /> Inspection Form Included: Q �w 4 w <br /> Comments Included: 7!N ��� <br /> � <br /> B R ature hone NumberInspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: ❑EXAMPLE 12 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />