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Waste Tireey & Inspection Rep" Inspection Report Number ■ <br /> CalRecycle CalStte of Recyclel' ia 181n(Rev.10110) 11 - 11764-89 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Sart A- Survey _ BLUE OR BLACK INK_ P_ EN <br /> Business Profile Inspection Details <br /> TPID- I , / t� I ,1 - I Inspection Type(Fill one) <br /> Site Suffix: "� -1 "� 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: �(,�n�OC !w1A coun 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ` Inspected By Inspector <br /> S co <br /> Physical ARils 31 1 0\ 5k5 �14� l Q () G5� <br /> e <br /> Cl^Ir1,)&rD Inspection Date a 1 1 <br /> tTime In Time Out J <br /> BusinesjRep 0 � Title \Csi ` 5C ' rl 41 AM O O AM <br /> , <br /> /� l�G V Q PM (9 PM <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 /> 9 Active 0 Passenger • Generator 0 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 /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 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 Q 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 /> M / m / m <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 EXTJ <br /> a <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 /> 2 <br /> Lu <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> 0 0 Other:§ I (( l- <br /> Comments zMkkf,y. (_l\1 Li 1cJ `C f� . Oa <br /> T()J'M'Q r\ + 1'�1 <br /> wen's C\AJ <br /> �1v v)C�lU ieMs ar alc-ks o+ toficun, <br /> Inspection Form Included: 9 <br /> Comments Included: <br /> siness Rep' Signature Phone Number Inspecto Signatur Phone Number <br /> INSTRUCTIONS/N BACK orrect:0 Incorrect: �l ® � E X A � L 1 2 3 62081 <br /> ■ Whi/Copy:CalRecycle Yellow Copy:Operator Pink Co y:L ■ <br />