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Waste ""'_'Urvey Inspection Report NumberWaste Tor & hspscUon Rep � <br /> Ca�Re�ydo State c California I 1 1245190 <br /> oe e u Caycling le 181(Rev.very(10) B(1(1 f�T� ey Form <br /> rffi(�l o I���ge `� <br /> Dept.of Resources Recycling and Recovery(CalRecycle) I�JJII lllei�f Il ��U Pagel <br /> `�l� BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: ""1 V I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� b"') CC Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> kCV44;i:4� \L PrIc,SIS <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM "�AM <br /> ® PM ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count QINho�e/PTE) (FII one only) . (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ((�� ° 0 Active Q Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> ��� Latitude Q Hauler Q Indoor <br /> O Q Inactive Sk Truck <br /> Longitude - Q Planned Q OTR o End-Use Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair *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 /> o Notice Of Violation Q Extension <br /> Q Q 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 m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years a <br /> Q o 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 /> Comments •��je�.��_-.► (-�.»E �'�.,�.-�- 1�t.A„��� L.•t,�� L�nt..�.. <�s.-�- —11��L,� <br /> Inspection Form Included: Q <br /> Comments Included:® <br /> usiness Rep's Signature Phone Num ? nspec or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ■ <br />