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1.12.7&Cl 4 C11111`# <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecyae alCaRecycle 18(Rev.10/10, Surve Form - Pa{,�e 1 11 - 117 6 8 3 4 <br /> Dept of Resources Recycling end Recovery(CalRecycle) Survey J <br /> "art A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection <br /> Ip ction Type(Fill one) <br /> Site Suffix: I I Is I 0 l I� I - f Q l l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier. S00f-1 JI �.n� c�w►L � Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 17 Inspected By Inspector <br /> Physical Add�ressm� L-!O�L_J.c�. - I I� I(� I - I t I I J � _ __ rn, I <br /> �'� o � <br /> Street <br /> Inspection Date II t) II <br /> rat73 ( <br /> City State ZIP Code Time In Time Out <br /> Business Rep - Title IAM 0 AM <br /> ®PM ��� ' Id ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> iFill one onl (Fill all that a <br /> Tire Count(Whole/PTE) I I ( y) ppI y) (Fill all that apply) (Fill all that apply) <br /> Q Active ® Passenger ® Generator Q Outdoor <br /> O ® Closed Q Altered AJ/AGPS Latitude I IFTI <br /> I I I Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - I � 1 - I1_��I _l Q Planned Q OTR Q End-Use Q Container_ <br /> Business Type(Fill all that apply) <br /> Q 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 11 <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 /> 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements DateM / 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) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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: Q- _ `/ <br /> Comments Included: ® ric <br /> - r y6ne��� <br /> Business Rep's Si -Phone Phone Number sec r' IgOe Phone Number <br /> INSTRUCTIONS ON BACK I Corr�ct:I� 1 orrect: I I E I X A rylE I I I 1 2 1 3 62081 <br /> ■ White Copy: alReWe Yellow Copy:Operator Pink Copy:LEA �� ■ <br />