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Waste Tire Survey & Inspection Repor,, Inspection Report Number <br /> CalRecycle Calt eof Califorcle 181 iRev.10/10) — ■ <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Survey Form - Page 1 I1 1196390 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- + 1 _ 0 Inspection Type(Fill one) <br /> Site Suffix: l ` ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ( ) / If Referral,choose referral type(Fill one) <br /> Identifier: r) Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name / Inspected By Inspector <br /> % <br /> Physical Address V I V <br /> Inspection Date t / 3 / l <br /> � Sc�cv� CA 1s'3�i1� l <br /> Business Rep Title Time In /l AM Time Out 0 AM <br /> SJ01 ' a v * PM � 5 0 (9 PM <br /> � <br /> 1 ~ S' Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> S (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 9 Active ® Passenger • Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer ® 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 <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 Q Q Notice Of Violation Q Extension <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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle A <br /> Q Q 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 �,\iW <br /> e� 1 J� 11�Spu �� <br /> w\ LA vs s o eA = <br /> N o V' S a3CA.JeUs 0+ c_vinLQrJ,- <br /> Inspection Form Included: Q <br /> Zoe'431-Z683 <br /> Comments Included: ® - <br /> Busine s R s ignature Phone Number Ins a tor's Signature Phone Number <br /> • • X � V ��� 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: �/ EXAMPLE 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />