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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California I 1 - 1210521 <br /> CatRacycIN181(Rev.10/1� Survey Form - Page 1 <br /> DK+t O Reaarcea Recyding and Recovery(C,,Recycle) BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile I Inspection Details <br /> TPID- inspection TYPe(Fill one) <br /> Site Suffix: , 5 , '4 1 Q Routine ` Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type Fill one) <br /> Identifier; -SCJ�n SM���- i- /yv�'� Q CHP Q CaWec7rcie Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date 9 / O 6 / 1 3 <br /> C 4 Time In t Time Out <br /> Business Rep Title O AM O AM <br /> " � • S D !PM 3 O 49PM <br /> w ✓� r�n+�itr.Grv► <br /> operatiomi Status Tire l'pa Business.Role Storage type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) FRIT all that apply) (Fill all that apply) <br /> r ' Q Active Passenger Generator Q that <br /> Latitude Q Closed Q.Al 413ted .: <br /> GPS - Q Hauler Q Ih(OOf <br /> o Q Inactive Q Thick <br /> Longitude — Q Planned Q OTRCdrrtalher <br /> Q End-Use Q :.:... <br /> Business Type(Pili 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 n- <br /> e / <br /> Yl� Ti»?e E itr -,-p <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 A 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entitles Complying with Manifesting Requirements Date <br /> Q 0 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 EXT} <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Q Q Other.§ <br /> z <br /> Comments ` <br /> u <br /> S P <br /> Inspection Forth Included: ^ „ <br /> Comments included:® <br /> Business Rep's gnature Phone Numberi s o Si ature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />