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:ilrQl3i/biYi�:-s i: �%S2 ♦ 4.•:-5?i '-{:�:{;-::, <br /> Waste Tire Su. vey & Inspection Reporl,, Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1226503 <br /> CalRecycle t8l(Rev.y(Ca[ Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> PartA-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: ( y O 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �� If Referral,choose referral type(Fill one) <br /> Identifier: <br /> Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> SCAvX �rr,Cdn� C�.�/V�t.l �loor� C�hne l <br /> Physical Address c) 4 rn iclL� <br /> Q81to Ave, <br /> Inspection Date <br /> Jtc_'A4� C44 Q ts- Time In Time Out <br /> Busi ss�,Repp Title Q AM Q AM <br /> P %1211 -1_pcf Trck,t 4-40_ 1 ® PM �� to PM <br /> C�v✓t �dLl/IYIC� 1T� 'mac ec�r. — -- --- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger ® Generator ,Outdoor <br /> O Q Closed 40 Altered Al/76 <br /> GPS Latitude Hauler Q Indoor <br /> Q <br /> O Q Inactive ® Truck <br /> LongitudeQ Planned ® OTR End-Use Q- Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 4p 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 ® 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 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 <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 EXE N <br /> 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 <br /> ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> Inspection Form Included: Qi_�-NLM� ` � <br /> Comments Included: ® �P 7 f y6 r-Q 7 <br /> usiness Rep's Signature Phone Number ns c r' igna re Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X 11 EJXJAJ P E I 1112131 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co EA ■ <br />