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Waste Tire Survey & Inspection ReporL Inspection Report Number ■ <br /> Cal Recycle State of California I 1 - 12 2 6 3 6 3 <br /> CalRecycle 1131(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A- SurVy_ <br /> Business Profile Inspection Details <br /> TPID- t ! 11 1 - Q I Inspection Type(Fill one) <br /> Site Suffix: 1 7 �1 l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S r, ��(� (,(�V�d1Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l Inspected By Inspector <br /> A-.\a . V ads3 `1 - I <br /> Physical Address U <br /> �j C A 15ii5 Inspection Date 2 / 0 / <br /> Time In Time Out <br /> Business Rep Title 77 rr^^ O AM } O AM <br /> Q II 1 ( L V ® PM l 0 ® PM <br /> — <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> Q Active Q PasseJn�ger Q Generator Q Outdoor <br /> O ® Closed Q Alterekl_/A N/A NIS, <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q 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 l <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other LA46c,(, ec 5101 <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 /> Q Q 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 EXT) N <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 U 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 [gin L� �lI T�a �l�,�vllVIA) <br /> C-17�r� n`��D 1�`sibl Of i,ac (l-- con Crxn• ,J <br /> Nc�Sc.s• 1� 1'uci�irM �IIGL� �J� (c c,� C.�1c,�_�c <br /> Z. �� r'fl,��� �5 skill �►�'�, s� <br /> Inspection Form Included: �c/ <br /> Comments Included: Q J L <br /> es I ature Phone Number Inspe is Signature Phone Number <br /> ?� 62081 <br /> INSTRUCTIONS ON BACK Correct:6 Incorrect: �c , E X A M LX 111213] <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co :L © ■ <br />