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Waste Tire Survey & Inspection Repon Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1226587 <br /> CalRecycle 161(Rev.10/1 <br /> y(Cao) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A- Survey __- -_ -BLUE _ .. <br /> Business Profile Inspection Details <br /> TPID- Inspection Q � � � I - � � Inspection Type(Fill one) <br /> Site Suffix: 1 l� 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local ' If Referral,choose referral type(Fill one) <br /> Identifier: S� O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Cen-�fal c,1,"`+n)n)'k Orn - t �1 <br /> Physical Address 3 - EJ z)�D <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep l_ Title O AM u f� O AM® <br /> T 1SbGL UpS - j. V ® PM 1 `� PM <br /> �� 1 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 /> ® Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned ® 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 0 Other IJ rQ <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> Q jo 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 EXE N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <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 �(kms A AIV-4c'c' �i tom. � �`�¢�Ci Cjn I? C�fl"(�I' Mc U,jl(�`��4011(A A)I Il l <br /> Set. (0 m���� IFo r<�\ <br /> Inspection Form Included: Q / p <br /> Comments Included: — <br /> Business s gnature Phone Number Insp tor's Signature Phone Number <br /> ----- - - - ,-�( 62081 <br /> INSTRUCTIONS ON BACK �Correct:6 Incorrect: X �_NJ E X A M P 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: © . <br />