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Waste Tire Sty, dey & Inspection Report inspection Report Number ■ <br /> CalRecycle CalRecycle1181(Rev.10/10) 11 - 1177707 <br /> Dept of Resources Recycling and Recovery(CalRecycle) Su rvey Form - Page 1 <br /> Part A-Survey BLUE OR R BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: t c) l —L (V Routine Q Re-inspection Q Referral Q Observation <br /> LocalC - If Referral,choose referral type(Fill one) <br /> Identifier: �(�Vt �� � � Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v rr Inspected By Inspector <br /> J\.frov 6,V T,,anspcv14_t ) <br /> Physical Address <br /> Inspection Date 5 / � <br /> iS .+�v� �a�l5 <br /> Time In Time Out <br /> BysPiness Re Title 1 0 AM _ 0 AM <br /> N1 ►{rS>�Zl I D OPM o 40 PM <br /> [ --- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 4 Active Q Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GP� Latitude Q Hauler ® Indoor <br /> O Q Inactive ®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 Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® 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 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 / Ffl <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXn PL <br /> PL <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 /> Comments <br /> Inspection Form Included: O G <br /> Comments Included: qa <br /> o� <br /> Business Reps Signat Phone Number 1 sp tor's fgnVure Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: 7X_4 EXA L 1 2 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Co :L ® ■ <br />