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N <br /> 'inti~.._ <br /> Waste Tire Survey & Inspection Report inspection Report Number ■ <br /> State of California <br /> Calucycle calRecycle 181(Rev.10/10) 11 - 1196368 <br /> Dept of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- Type pe(Fill one) <br /> 0 Site Suffix: J9 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier Sao 6A(I 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> SO CA-(Al QA-Ij CA - <br /> 19 Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM 'I : 0 0 61 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 /> ® Active 0 Passenger ®Generator 0 Outdoor <br /> GPS Latitude 0 0 Closed 0 Altered 0 Hauler 0 Indoor <br /> 0 0 inactive ID Truck <br /> Longitude 0 Planned 0 OTR 0 End-Use 0 container <br /> Business-Type(Fill all that apply) 0 Dismantler 0 Tire Derived Fuel <br /> 0 New Tire Dealer 0,Auto Repair 0 Trucking Fleet 0 Government 0 Retreader <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS, <br /> V I A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC;§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M M <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§19459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) c� <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations <br /> 0 0 Other:§ <br /> Comments 03 f4c_i;f,,— i n< tj k,--, cA yvk <br /> b+Jr- <br /> NO 110 1 4+11 cl_ws 0 f a C4.1 0f f-ein <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> Bus' ess Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: E X A IMAL IJK 1112 a <br /> 1 0' <br /> 0 White Copy:CalRecycle Yellow Copy:Operator Pink CNX.V Li 0 <br />