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inspection Report Number <br /> Waste Tire Survey & Inspection Report ■ <br /> ia <br /> CalRecycle CalRecyclel'181te of n(Rev.10110) _ I1 - 12 2 6 6 5 8 <br /> Dept of Resources Recycling and Recovery(CalRecycle) Su rvey Form Page 1 <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- y ` q q u Inspection Type(Fill one) <br /> Site Suffix: 1 Cp �( 1 ` 1 , I Q Routine Is Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: J Ur,, /J�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 11 Inspected By Inspector <br /> fi cc ` �5 S 3 a - I C� I Eseo{ <br /> Physical Addresss <br /> Inspection Date <br /> n41(�-C'LeA, Time In Time Out J <br /> AM <br /> Business Rep /� Title ' 1 : Q C) AM O PM ( Q 0 PM <br /> '30�SeIp. I u� SU Q Operational Status TireTypeType Business Role Storage Type <br /> So (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) , <br /> S Active S Passenger ® Generator Q Outdoor <br /> O PS Latitude Q Closed Q Altered a Hauler 0 Indoor <br /> G <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 /> Q Retreader Q Tire Derived Fuel <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station S 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 Q Notice Of Violation Q Extension <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 N <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18 - (Required for NOV or EXT) <br /> 459.2.1 Submittal of Comprehensive Trip Logs within 90 days a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q Q Referred/CalRecycle Enforcement <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 2 <br /> LU <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:§ 1 (� z <br /> Comments �,,,,,,,� .1 All L Ito 1-n I I I <br /> pr��, ou,5-1�=�, o.� L(�c� l4cr�l�n G <br /> -fin,s w�� -c-i-\Ck A�'o 5 n = <br /> V to((����- <br /> Inspection Form Included: Q <br /> Comments Included: ® <br /> B iness p's Signature Phone Number Inspe is Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect- X �O g E X A M L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />