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Waste Tire Su. Bey & Inspection Report alspectl,,tt Report Number ■ <br /> CalRecycle Cia <br /> alRete cyclel1fo181(Rev.10/10) 11 - 1176809 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form Page <br /> Part A- Survey___ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: I U l� 5 O - I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: �� -(J1,L Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or F cility Name Inspected By Inspector <br /> ,1QA waae j) _ l /� <br /> Physical Address I �J I &n ESu� <br /> Inspection Date <br /> Time In Time Out I <br /> Title O AM ® AM <br /> BusinessRep <br /> 1 I O PM I 3 O PM <br /> i Operational Status Tire Type Business Role Storage Type <br /> rn <br /> , <br /> V (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> Active Q Passenger 0 Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <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 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 l- Sl <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other Tq:W U�/L��j( <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q 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 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 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 /> Lu <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators (0 In Compliance-No Violations o <br /> Q Q Other:§ L n_. I_ 1 <br /> Comments � aI�Q Uel�Q ,yA54�CN 1 �\ S ( L 4'�l hil <br /> 1� o4 6Xor)r b 61nl"Pr) <br /> Inspection Form Included: Q I' / /_ - <br /> Comments Included: - — (J -/ - vCIJv� <br /> ®-- <br /> uslness Rep's Signatur Phone Number Inspec 's Signature Phone umber <br /> 62081 <br /> INSTRUCTIONS ON BACK ECorrect-f� Incorrect: g E X A L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co y: © ■ <br />