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Waste Tire Sup vey & Inspection Report 'Inspection Report Plumber ■ <br /> CalRegde CaaStte of Recyclellia 181n(Rev.10/10) I1 - 1230388 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form — Page 1 <br /> Part A-Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� Q � � � o � � Inspection Type(Fill one) <br /> Site Suffix: I* Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. h ToC V� U V^%« �Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name `^�"n� � Inspected By Inspector <br /> Physical Address 6 U I M TTA <br /> �1k67 �,. g ��� 1 ��' 111 <br /> SkoCom•\_0 V-1 �20� Inspection Date / l 7 / 1 <br /> Time In Time Out <br /> Business Rep Title AM O AM <br /> \ 4 S Q PM ® *PM <br /> Svc- �.• <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 /> I <br /> 9 Active is Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler * Indoor 161 <br /> O Q Inactive 40 Truck Longitude - Q Planned 0 OTR Q End-Use 0 Containers <br /> 40 <br /> Business Type(Fill all that apply) <br /> 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 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 <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 EX7) 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 /> LU <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 is In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> ',Q-o���h e: wa-�1�f <br /> C5 C_ cmiacem <br /> Inspection Form Included: Q <br /> Comments Included: 0usiness Rep's Signature Phone Number Inspector's Signature LY` P`h7oone Number <br /> INSTRUCTIONS ON BACK I Correct:I• Incorrect: EXAMPLEI 111.2L3] 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />