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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 181( 11 - 12 2 6 3 8 5 <br /> CalRecycle 781(Rev.10/10) Survey Form - Page � <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> _ -- BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: Ll C1 1 © 1 S Routine Q Re-inspection Q Referral Q Observation <br /> Local / _ ` If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 14 rz c ryl�tJ�e.� <br /> 8 t:: ~1 PC"- <br /> CA <br /> Inspection Date <br /> v ` Time In Time Out <br /> O PM AM <br /> Business Rep Title 4 1 : 0 <br /> ®AM <br /> p� � � PM <br /> I�r b\D 1�rtilCZ �c, �Lrf� <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) , , <br /> Active I& Passenger 0 Generator ® Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End Use Q Container <br /> Business Type(Fill all that apply) <br /> • New Tire Dealer • Auto Repair Q 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 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 / m / m <br /> N <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle12 <br /> Q Q 14 CCR§ - (Required for NOV or EXT N <br /> 18459.2.1 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 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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators #In Compliance-No Violations o <br /> Q Q Other:§ -- - - - <br /> 6 <br /> Comments <br /> V <br /> Inspection Form Included: 01 <br /> Y�-7 <br /> Comments Included: <br /> usiness Rep' 'gnat Phone Number n p or' nature Phone Number <br /> _..- 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: NA E X A M L11;1 <br /> 1 2 3 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy: <br />