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Waste Tire Sulivey & Inspection Report nspection Report Number ■ <br /> CalRecycle state of Calile fornia <br /> (R I 1 - 1177744 <br /> Ccyclin and <br /> (Rev.Recovery <br /> Survey Form - Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- -7 Inspection Type(Fill one) <br /> Site Suffix: I © 0 ' / © * Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ! t Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Ss west- ,> q - l a I i('� TTO <br /> Physical Address <br /> X611 s• A;Toc� w0.�e <br /> Inspection Date <br /> CA ys 206 <br /> Time In Time Out <br /> Business Rep Title V A <br /> co-. Svc. SeeC�aa� I I . O 0 (D PM � 1 1 � O 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 /> }CJ * Active Q Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GP$ Latitude Q Hauler Q Indoor <br /> O Q Inactive I* Truck 4 <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 0 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 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 EX7) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> Q Q 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 !VArz wQS�� IYLSP-(' - d n 0AmsR C,'IN 'lam\^j dLJL�Q <br /> Nb V )4yr *S c7,� Cahce r» <br /> Inspection Form Included: O _ �- I I ! //�`�K/b �j <br /> Comments Included: 1. 20 �.-32SN <br /> Business RcWs Signature Phone Number Ins ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: � � g EXAMPLE 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />