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Waste Tire Survey & Inspection Report inspection Report Number <br /> ; e California CalRecycle Ry181 ev.10/1o) I1 - 1230351 <br /> Dept of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> � � � � n � � <br /> Site Suffix: ` i Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: QrL>> C®u��l Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> -Dc-PSv�y�h � � c� 9-Dc- <br /> Physical <br /> hysical Address <br /> 1�i do �'e casco ave- -- - - <br /> Inspection Date Z g 1 <br /> �V CY Time In Time Out AM <br /> Business Rep Title /'� *AM <br /> QPM QPM <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 /> ® Active 0 Passenger Generator 0 Outdoor <br /> G pS Latitude <br /> o Q Closed Q Altered Q Hauler Q�60 _ <br /> o Q Inactive 0 Truck <br /> Longitude — End-Use Container <br /> Q Planned O OTR <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair S 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 0 Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> OO 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / IT] <br /> Q 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> a <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> w <br /> O 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 O Other:§ <br /> Comment <br /> s � �� <br /> `P`h..— �� A\e <br /> Inspection Form Included: Q <br /> Comments Included: 0 35,- <br /> Business Rep's Signature Phone Number AInsper's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: q EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />