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Waste Tire Survey & Inspection Repo Inspection Report Number <br /> Cal Recycle Stat CalRecycle California v.10/10) - 1226261 <br /> ■ <br /> y Survey Form - Page 1 I1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Sart A-Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: I 3 8 q �! I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Localr If Referral,choose referral type(Fill one) <br /> Identifier: ,)aka 'JGC, vAf '1V\ �.Ul/y'l fZ� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> St-OG�6VI - r o1 v Cc_(c l e 67 vi e'r - 1 CU 1 <br /> Physical Address <br /> f <br /> 18� Z �- f�,.rUl�'i� CJC�J <br /> l Inspection Date L 1 Z t J <br /> 'S+ -"r'Kf-Zv\ l <br /> Time In Time Out <br /> Business Rep Title ) ?? AM AM, <br /> / J O PM O PM <br /> J Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) -6 ®Active ® Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ® 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 I✓�Cj�r r�� 1�1/���t �y <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 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 /> 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 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 /> 2 <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 <br /> Inspection Form�nc <br /> ncluded: Q <br /> q <br /> Comments luded: <br /> B ine;s p' gnature Phone Number cteignature Phone Number <br /> ■ <br /> 0 � � E X A�M PIL(EI 1112 3 62081 INSTRUCTIONS ON BA Incorrect:Correct: � ■ <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />