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Waste Tire Survey & Inspection Reportinspection Report Number <br /> CalRecycle State of California I 1 - 1230132 <br /> R ry <br /> CalRecycle ' (Rev. (CalRecycle) Survey <br /> 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- ` � � � � � � _ O � Inspection Type(Fill one) <br /> Site Suffix: I I* Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local G- r.- If Referral,choose referral type(Fill one) <br /> Identifier: �7+�����1/�I W�l� ll� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1 <br /> Inspected By Inspector <br /> Physical Address <br /> � S2�jb N,Z�vrn�U � Vim_ <br /> Inspection Date <br /> C L Time In Time Out <br /> Business Rep Title ' U h 1 O AM f� 3 � . ®AM <br /> `� U PII 0 PM <br /> 4x\`�NM �o1;�c SCI-N-1(0- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> h (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> U <br /> Active 0 Passenger ® Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ® Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 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 A HAULING AND MANIFEST REQUIREMENTS <br /> 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 / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> a <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <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 w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments XA(n4e-- AA f", l U'\ <br /> -( _ <br /> 0 J of u f e..A-S Cp W')Cern <br /> Inspection Form Included: 0 B s R �IL—p , 0 <br /> lit <br /> Comments Included: ture Phone Number lnspe t is Signatu LJvI(/I1 _( b <br /> � <br /> Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A E 1 111 <br /> 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co y:L <br />