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Waste Tire Survey & Inspection Re orlb Inspection Report Number <br /> CalRecycle p p <br /> y State of California 11 - 1245291 <br /> CalRecycle (Rev.y(Co) 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- r^ Inspection Type(Fill one) <br /> Site Suffix: �c ( v • Routine Q Re-inspection Q Referral Q Observation <br /> Local t If Referral,choose referral type(Fill one) <br /> Identifier: SUx.J0Ctjw%r) IJD•�lflQ CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I Inspected By Inspector <br /> Skc./e.Jvne�s�p;.►e :�s;� Cra, �i., v{cres _ '^ <br /> Physical Address <br /> SSS-- <br /> r A C15 Inspection Date <br /> l(� V •L Time In Time Out <br /> Business Rep Title S O AM O AM <br /> 40 PM � � D * PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) r _ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �Q 1@ Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 8 Indoor <br /> O Q Inactive Q 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 0 OtherG � �en <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 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 /> Q Q 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 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXTJ 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 /> f <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 In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments OLIN--{-�3 <br /> ofurkAAs a�- cc�nCesn <br /> Inspection Form Included: Q o 7 <br /> Comments Included: g2•- <br /> usm ss Rep'sleignWre Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E I X I A ME 1 2131 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L <br />