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Waste Tire F ley & Inspection Repoi Inspection Report Number <br /> State of California <br /> CalRecycle I 1 -1176611 <br /> CalRecycle 781(Rev.10/10) Survey Form - Page 1 <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: Z 4 y 2 S 3 0 ( ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �c(mv <br /> �cll_� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Aw,,Y7'CCS S I I r C C cy . Cl - 1 U <br /> Physical Address 3 <br /> 8of <br /> 3 3 L <br /> Inspection Date Q <br /> Time In Time Out <br /> Business Rep Title ® AM 1 /^� ® AM <br /> l`1 1'} (Lt1✓1 yr i TT,y 1 0 PM V Q PM <br /> — - — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I 1 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' ® Active ® Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> C.a�G Latitude - - -- — - - __2 H uler- ® 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 /> 0 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> ---- ---- --- ------- - <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> -- - — -- -- ---- -- -- Q Notice Of Violation Q Extension 1 <br /> Q Q 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 / 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 EX7) N <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 /> 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 <br /> Inspection Form Included: Q <br /> Comments Included: -- ZREL Ph , <br /> Business Rep's Sign ture one Number nspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: EXAM 1 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop�,LE <br />