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02 Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State CaliforniaI 1 - 1210435 <br /> CalRecycle 1611(Rev.y H0) 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- 11,, Inspection Type(Fill one) <br /> Site Suffix: ' "l 0 1 Q Routine Q Re-inspection • Referral Q Observation <br /> Local 1 /0 u� n If Referral,choose referral type(Fill one) <br /> Identifier: N�] C,(U 1/�t -� 1 'J Q CHP ®CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l Inspected By Inspector <br /> Physical Address C� J7 <br /> �%_w ej� rz-� <br /> Inspection Date / d <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> �l <br /> PM 3 O v SPM <br /> V�4 i`�tl,¢.` Y�-V�,y U`(�Ll,l7 C/�, '1>>fil,��T 1 t► s- <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (FII all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q P_a�s nger Q Generator Q Outdoor <br /> O ® Closed Q /►Altt/ere� PIA � <br /> GPS Latitude Q Hauler" ' Q InddA <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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other N I� <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 O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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 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 `l <br /> no-- 1i64cnsrsn <br /> ri s TPtz' <br /> Inspection Form Included: <br /> Comments Included: Q �.•) / <br /> B fines Rep's Signal NO Phone Number Insp c or's Signature Phone Number <br /> INSTRUCTIONS ON B K Correct:0 Incorrect: IIIIIIIIE X A M P L E 11 <br /> 12 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA ® ■ <br />