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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California <br /> CalRecycle 101(Rev.10/10) Page 1 11 - 1230395 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- <br /> Inspection Type(Fill one) <br /> Z � <br /> Site Suffix: 0 4& Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> TOO-A'lU%1N co V OCHP oCalRecycle o Complaint 0 Educational Visit 00ther <br /> Business or Facility Name Inspected By Inspector <br /> '31. '�� ov,\ <br /> Y"'&v 5 - 1 0 <br /> Physical A dress 3 c� <br /> Inspection Date <br /> Time In Time Out AM <br /> Business Rep Title 0 '1 <br /> 4 \ , : C-) -3 *0,P'M t . : S C 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) -3 ?- (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 40 Passenger 4& Generator ID Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler or incloor <br /> 0 0 Inactive 9 Truck <br /> Longitude 0 PlannedT <br /> XR 0 End-Use 0 Container&A <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 FA HAULING AND MANIFEST REQUIREMENTS 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 <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <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 <br /> .0 . 0 Other:§ <br /> Comments&, v\. AA_Q <br /> 0 <br /> j2nkX.0% LX)OL% VN isNe� <br /> Ell" <br /> Inspection=Form Included: 0 <br /> Comments Included: <br /> uded:: 400 <br /> 40 <br /> Business A'ewdsFignature Phone Number rinspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: M A '14-1 q I KX�I A I M PLJEJ 111213 62081 <br /> ■ 1 W 1I <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />