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..:.-.......___.... _.. . tr...._..._,-''"„' __......tea w uvA, .. .:..... ..._... _....- �._......:.c_._.__.._.:.. :.... • .__.�__..._....... _.._....._.. - .._._..... .-...___.._..._.. _ ... <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRec cle State of California <br /> Y CalRecycle (Rev.y(Cal Survey Form - Page 1 11 - 1210 219 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 6 0 L-1 L( C! C I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local c , I If Referral,choose referral type(Fill one) <br /> Identifier: -�(�,� � `��- C ��V�,A Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1111 Inspected By Inspector <br /> Physical Address j L, ( APS,gY lI J uLA <br /> j l Inspection Date -7 <br /> Time In Time Out _ <br /> Business Rep Title 9 AM ®AM <br /> l l l 0 O PM \ Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> 61 <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/ TE <br /> ® Active ® Passenger ® Generator ®Outdoor <br /> o Q Closed Q Altered <br /> �PS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - 0 Planned Q OTR ® End-Use Q Container <br /> Business Type(Fill all that apply) <br /> (0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 I A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Q Q Notice Of Violation Q Extension <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 O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q O 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 /> 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 /> 6 <br /> Comments <br /> m <br /> Inspection Form�nc�uded: Q I, aCA <br /> Comments ncuded: (01- Y` 2l� <br /> Business Rep's Signature Phone Number sp cto s gnatur Phone Number <br /> INSTRUCTIONS ON BACK I Correct:0 Incorrect: � ® � E X A M L 1 213 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink op :L <br />