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y�Atit--_. 's liiFi+L:wriLiil->._i i_.... ,-iiufi�.... .. =:-5 r,i___r.... i:I/ltv:':l:..Y.'...:.::/ •..:_._...r_ -r___ <_.... .. ............... _.... _ _.. .. <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1226685 <br /> CalRecycle 781(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A-Survey _ -- <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: ` J 0 I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ` /`� If Referral,choose referral type(Fill one) <br /> Identifier: �j,n ��Gc �.n� �—VL� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address Ci �' AYCA.rn V C,._ <br /> l �o� <br /> Inspection Date 1 } / '-7 / L <br /> ( 1 <br /> � Time In l \ Time Out <br /> Title O AM �AM <br /> Business Rep � � / Q.>4- G ® PM S �� &PM <br /> ` <br /> Glc ' `C,v- `^`-� � tiOperational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) , 4D Active Q Passenger 0 Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude — Q Planned ® 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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder V Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility7NFOrRCEVMENTSTATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS otice 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 m / m N <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§ (Required for NOV or EXE <br /> 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q Q Referred/CalRecycle Enforcement <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers � <br /> w <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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 ,s <br /> (.� 6CyK.m eki. <br /> Inspection Form Included: Q _ pJ'p / _ <br /> Comments Included: '^' ` �� <br /> Business Rep's Signature Phone Number Ins ct 's Sig re Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � W E X A L E 1 2 3 ■ <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink A <br />