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Inspection Re orlonspection Report Number <br /> Waste Tire Su. Bey & spe p � <br /> CalRecycle CalReoy�e'181(Rev.10/10) I1 - 1242357 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �y Inspection Type(Fill one) <br /> Site Suffix: ( 5 16 a 1 9 - I * Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: /a ^,; V`r\ Cv��/ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �1 \�Y Inspected By Inspector <br /> .s o , I - I C) 1 M fiy <br /> Physical Address <br /> S�G` �� 521� Inspection Date Q Z <br /> 1L�p� Time In Time Out <br /> Business Rep Title ' 1 * AM 5GJ AM TSV F`IS O PM QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> J <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> /(� <br /> 0 Active Q Passenger A Generator Q O cl <br /> D Q Closed Q Altered (/� \ <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ( New Tire Dealer Q Auto Repair 0 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 <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 <br /> 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 EXE N <br /> a <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 /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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 <br /> Inspection Form Included: Q �hone <br /> Comments Included: <br /> Signature Phone Number Inspe tor's Signature Numb <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: NJ E X A M P L E 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA © ■ <br />