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Waste Tire SL.. vey & Inspection Repor ,, Inspection Report Number <br /> State of California <br /> CalRecycle 10/10) <br /> I 1 - 1242321 <br /> CalRecycle (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- O Inspection Type(Fill one) <br /> Site Suffix: J ® Routine Q Re-inspection Q Referral Q Observation <br /> Local aIf Referral,choose referral type(Fill one) <br /> Identifier: SCkA J 0 USI r1 CwAn O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name G Inspected By Inspector <br /> .1 n'�crn41,TiU1\q,� Pt�p�r- - �. 0 � C3Ct�T b <br /> Physical Address <br /> Inspection Date "j / l h <br /> l/ I <br /> Time In Time Out <br /> Business Rep Title G 0 AM h 0 AM <br /> y, (`Nan•, rrc�W��3 J O PM V 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 /> 0 Active Q Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered 1\)/1 <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned e OTR 0 End-Use Q Container <br /> Business Type(Fill all that apply) Foy 1a <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 <br /> Q Service Station Q.Hauler Q Agriculture Q Shredder • Other PArCon,Poin <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 O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Q Extension <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Re <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days quired for NOV or EXE <br /> N <br /> r; <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement � <br /> f <br /> O O 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 /> 010 1 Other:§ 1 <br /> Comments w <br /> Inspection Form Included: Q _ <br /> Comments Included: S q Z - � <br /> Pusemess Rep's Signature Phone Number Ins ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A M P L 1 213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L91/ ® ■ <br />