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Waste Tire Sup vey & Inspection Report Inspection Report Number ■ <br /> CalRecycle of CaalRecyclel'fornia 181(Rev.10/10) _ 1 I1 - 1226525 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form Page <br /> BLUE OR BLACK INK PEN <br /> Part A- Survey_ <br /> Business Profile Inspection Details <br /> TPID- I Inspection Type(Fill one) <br /> Site Suffix: —1 lel I ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalC If Referral,choose referral type(Fill one) <br /> Identifier: J cl,n�O ctf w f) C0Ltn+j Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> rn_�On _f runeeo,(& ,+jan <br /> Physical Address 3 _ O <br /> I SCD <br /> Lvu,,'� AVe. <br /> �A Cf5-33D Inspection Date <br /> L 44)j O <br /> A I Time In Time Out <br /> Business Rep Title <br /> ' Q ®AM 1 I 0 ® AM <br /> I <br /> 0 PM I 0 PM <br /> Operational 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) , 0-1 <br /> ® Active Q Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> D Q Inactive I*Truck <br /> Longitude - Q Planned Q OTR Q End-Use • Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 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 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / 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 EX!) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> Lu <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:§ II II� <br /> Comments n -r ) -+I, <br /> �n� u <br /> �( 1u,fQv S an ern <br /> Inspection Form Included: Q ?/ <br /> Comments Included: ein, G +S M� <br /> ®— ep's Signature Phone Nu Ins a tors Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [C:7orrect� Incorrect: t E X A M P L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />