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Waste Tire Spey & Inspection Report inspection Report Number II� <br /> CalRecycle Cte of alRecyclel1181(Rev.10/10) I1 - 1210517 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- q q ^ _ O Inspection Type(Fill one) <br /> Site Suffix: Routine 0 Re-inspection 0 Referral 0 Observation <br /> Localr If Referral,choose referral type(Fill one) <br /> Identifier: ( J d a II f) C��'� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> S&IA �- 7111LAA/W1 n 3 _ <br /> Physical Address 1 0 1 CS�OTTO C <br /> r11 9S3 Inspection Date I / / / I <br /> l.s SIA / Time In Time Out <br /> Business RepTitle � O AM O AM <br /> pv"a x V11.1 W 0 w s ® PM 10 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 /> el 0 Active 0 P��a��senger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Alt>sr4 <br /> GPS Latitude 0 Haufer'4 0 In r <br /> 0 0 Inactive 0 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 /> 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 /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 EXE <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 ®In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments jstm hI > IS N <br /> 131 ail ► dr .0 sa�S ( �,��nc�rn_ <br /> Inspection Form Included: 0 <br /> 9 <br /> Comments Included: 411- a. ) ��v�7�� <br /> Business Rep's Signature Phone Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A M P L E 11213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy © ■ <br />