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Oa Waste Tire Survey & Inspection ReporL Inspection Report Number <br /> te <br /> C81RecycleCta alRecyclelifornia 181(Rev.10/10) Survey Form - Page 1 I1 - 1230300 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- i n ( � _ Inspection Type(Fill one) <br /> Site Suffix: 1 "� e Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �\ 1 If Referral,choose referral type(Fill one) <br /> Identifier: SUn J Q U1 y U,1 ^ C°u" _� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or F1acility Name Inspected By Inspector <br /> e l l- (_0 <br /> Physical Address <br /> 3015 S_ 1`� wvJ. <br /> �� CA `tSZ,15 - <br /> Inspection Date � / � V / f S <br /> �l <br /> Time In Time Out <br /> Business Rep Tide ) 0 AM 0 AM <br /> ` O 0P I S70 PM <br /> 5��•h- � 115v� o rEl., ��neS' <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 /> f '0 6 Active 0 Passenger • Generator 0 Outdoor <br /> O 0 Closed 0 Altered /,A <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O Q Inactive ®Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 119 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <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 A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q 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 /> PRC§42956-Registration/Decal in Vehicle <br /> 00 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 EXT) N <br /> a <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 /> LU <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 <br /> � <br /> j i <br /> �S `f notcA <br /> T- <br /> Nh Vi6) C'Gnce-rn4 <br /> Inspection Form�nc <br /> ncluded: 0 a � w <br /> Comments luded: ® , <br /> Business Rep's Signature Phone Number In pe is Signature Phone umber <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: 7X*7 1 E X A L 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co lk:L <br />