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OZ Waste Tire ey & Inspection Rep" Inspection Report Number ■ <br /> CalRecycle CalStte of Recyclellia 181n(Rev.10/10) I1 - 1176482 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK_PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> � � <br /> Site Suffix: 1 b ( o Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: f)i G.41A1�' CU1 (1� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` I_ Inspected By Inspector <br /> Physical Address �PFn <br /> 13So� ►� � Ccs f�,; � � . <br /> LJ� q Inspection Date <br /> �"`� c Time In Time Out I <br /> Business Rep Title q &AM `I AM <br /> 1 3 v 0 PM I � V v 0 PM <br /> L C` ^S �� 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 /> ® Active Q Passenger ® Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> D Q Inactive ® Truck &L-- <br /> Longitude - Q Planned OTR Q End-Use 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 [' <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 Notice Of Violation Q Extension <br /> Q Q <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 /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / FTI / 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 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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators if In Compliance-No Violations o <br /> Q Q Other:§ <br /> CommentsI N <br /> n ) a <br /> Inspection Form Included: Q ) <br /> Comments Included: I&l — <br /> Business Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> - ----- 62081- -- <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EX A PJ[X 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C6 <br /> © ■ <br />