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Waste Tire SO & Inspection Rep�pection Report Number <br /> CalRecycle p - . <br /> State of CaliforniaCal'rfornia <br /> CalRecycle Survey Form - Page 1 1 41 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 1 I S ( _ © ( Inspection Type(Fill one) <br /> Site Suffix: �l I ti Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Scu) 3 C5 w h (OU44'n Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> Inspection Date / `7 / l 1 <br /> Time In Time Out <br /> Business Rep Title 10 AM 10 AM <br /> ` 71 <br /> 1 V v Q Q PM O O O PM <br /> - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) , G r_ (Fill one only) (FII all that apply) (Fill all that apply) (Fill all that apply) <br /> 40 Active 0 Passenger 0 Generator ® Outdoor <br /> o Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive O Truck <br /> Longitude - Q Planned 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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other F�r� <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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 1� <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 EX7) N <br /> c <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 /> W <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 <br /> in Compliance No Violations o <br /> Q Q Other:(n§� 11�� LL -- - ff 1111-- _ <br /> Comments Y�S1 ec���osl Off' s m� D nTn 15 (8U/LC/ <br /> ova, rA5 n� �►'- <br /> -- - - i CA 44 1DA& 01Y i rf�- <br /> Inspection Form�nc <br /> ncluded: Q ? ` Q_ <br /> Comments luded: ® e U �er <br /> _ Bu ' ss Rep's Signature Phone Number b1nspe Signature Phone Number62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X g E 112 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink op ® ■ <br />