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Waste Tire Su. vey & Inspection Report Inspection Report Number ■ <br /> CalRecycle CalStte of Recyclel1ia 181n(Rev.10/10) <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form _ PaI1 - 1226226 <br /> Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: , Ll Q ' ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: S!,vj -)uXrt"jV\, 60,'V�_It-, O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Coy X03 l - U i A->e.m best,, <br /> Physical Address `� <br /> -�`{Lt0 <br /> Inspection Date <br /> '��►'��G�- GA q533-7Inspection <br /> In Time Out <br /> Business Rep Title <br /> f®AM0 AM <br /> pm <br /> Operational Status Tire Type Business Role I Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) I (Fill all that apply) <br /> (� ® Active ® Passenger 16 Generator Q Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude Q Hauler it 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 /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet 0 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 /> ® 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 /> _ 0 Notice Of Violation Q Extension <br /> Q 0 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 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> O 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> W <br /> W <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> O Q Other:§ <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business Rep's Signature Phone Number In e r i ture Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correct 0 Incorrect: � ® � E X A P L 1 1112131 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop : ® ■ <br />