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Waste Tire SLftey & Inspection Report +nspection Report Number ■ <br /> CalRecycle <br /> State of <br /> (Rev.10/10) I1 - 1242090 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Su rvey Form - 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: 1 �! &Routine Q Re-inspection Q Referral Q Observation <br /> Local C If Referral,choose referral type(Fill one) <br /> Identifier: , LC/j'✓(12 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name !• Inspected By Inspector <br /> I <br /> Physical Address ��L,4 <br /> 3-7-L/�5- Pe,�e_es(�iA KC*'_-j . <br /> Inspection Date <br /> R=��2i s l <br /> Time In Time Out <br /> Business Rep Title ®AM AM <br /> V 90 O PM I C ,-7 O PM <br /> Ayw,� OSx"LiV\- <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 /> 0 Active ® Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive Q 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 I A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 /> Q Q 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 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> w <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 /> Sc e— <br /> Inspection Form Included: <br /> Comments Included: Mir <br /> Business Rep's Signature Phone Number qpActoeWig#ure Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: E A E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: ® ■ <br />