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Tire urve Ins Reposrtlnspection Report Number <br /> Waste e S y & Inspection p � <br /> Stte of <br /> CalRecycle CaaRecyclel1ia 181n(Rev.10/10) 1 - 1210481 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Survey Form - Page 1 I <br /> part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection_ Inspection Type(Fill one) <br /> 1- <br /> Site Suffix: JJ S • Routine 0 Re-inspection 0 Referral 0 Observation <br /> Localt If Referral,choose referral type(Fill one) <br /> Identifier: �C\ "JjC)Cu1 1 1-N CU,,r{� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> M C lb 1A eTs Lk(Nu fi-,_ Se c v; z,� G _ I <br /> Physical Address J 3 1 I 0 I C-S�j(���6 <br /> 10 S sv s_ 1A fzj , l <br /> �fc�lGY1 �u ,n C ' 7 31 Inspection Date 5 2 Cd 1 3 <br /> J (• Time In Time Out <br /> Business Rep Title (� 0 AM 0 AM <br /> 3 . " Q PM S 5 0 PM <br /> �Yo`n 0 C S c.ul�,nr� S,s.n' u mfr, <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active ® Passenger 0 Generator • Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O 0 Inactive • Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 416 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments 1 1 <br /> G,,n_/� <br /> Z3 Ali rA aen-t n J Gt_1 n-NS b4 co n (a n, <br /> Inspection Form Included: 9\ <br /> Comments Included. <br /> Bushes Rep's Signature Phone Number Inspe r s Signature Phone Number <br /> INSTRUCTIONS ON BASK Correct:0 Incorrect: 7V Z E X A L( 1 12 13 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co y: �� <br />