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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Cal Rec cle State of California <br /> Y CalRecycle 187(Rev.10/10) 1196348(Cal Survey Form - Page 1 I1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: (ij b 1 ® Routine Q Re-inspection O Referral Q Observation <br /> Local \ / If Referral,choose referral type(Fill one) <br /> Identifier: Sqy" Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name--�-- Inspected By Inspector <br /> Physical Address j+KA-t-US <br /> uLA <br /> a.�t1� C , �r►2on,f- st , <br /> Inspection Date l L 3 <br /> Time In Time Out <br /> Business Rep TitleAM O AM <br /> _ J ( L "4 ' Ll S O PM / O O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> oZs <br /> Active 0Passenger S Generator ® Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude ®Hauler ® Indoor <br /> O Q Inactive O Truck <br /> Longitude - Q Planned Q OTR ®End-Use O Container <br /> Business Type(Fill all that apply) <br /> • New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer O Collection O Crumb Rubber <br /> Q Service Station 0 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 � Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years d <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators i®In Compliance-No Violations o <br /> O O Other:§ <br /> Comments <br /> Inspection Form Included: Q - <br /> Comments Included: * - — <br /> Bu ' s Rep's Signature Phone Number I pe t*JE <br /> Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: ®� E X A 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />