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Waste Tire Sup Bey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1230402 <br /> CalRecycle 181 cover (CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Surveyf _— _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � Inspection Type(Fill one) <br /> Site Suffix: • Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Soh TO" Ul y\ Cw V,1 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Co.l S v'j - Co t r.�a 7 q _ , \ <br /> Physical Address 3I V <br /> C, <br /> C <br /> Inspection Date 0 1 / 1 q / 1 <br /> «�y q S3�b <br /> Time In Time Out <br /> Business Rep TitleC) C) O AM U O AM <br /> PL/1 � + � 4 PM <br /> \ e 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 /> Active 0 Passenger 0 Generator 4k Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — Q Planned 10 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 Other Pa�; � e /vl�ir�QQCrij C <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I 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 <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 /> 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 1i _� <br /> 0.S S \ V�CJw�,r <br /> f Tom. { � <br /> o Y�.o <br /> r ��\ � - <br /> Inspection Form Included: Q' It <br /> oG` fiCJO—d <br /> Comments Included: � <br /> usiness Rep's Signature one Num ' Inspe or's Signature Phone Number <br /> INSTRUCTIONS N BACK Correct:40 Incorrect: � E X A M P L E1 11 �2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © 0 <br />