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Waste The Survey & Inspection Report inspection Report Number <br /> ■ <br /> c1dRecycle state of California 11 - 1255928 <br /> CalRecycle 10(Rev.10/10) Survey Form - Page I <br /> Dept of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Inspection Details <br /> Business Profile Inspection Detail <br /> Inspection <br /> T <br /> Type(Fill one) <br /> TPID- C <br /> Site Suffix: + -3 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Localif Referral,choose referral type(Fill one) <br /> Identifier: Sa V-\ _7 0 Ctq ui,A C(.V Vj 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name inspected By Inspector <br /> -beukc-, Vocu_t�ecL 3 Cl - 0 ) 1 <br /> Physical Address luary AL�kAgZIL' <br /> Inspection Date <br /> Time In Time Out <br /> 41 AM f AM <br /> Business Rep Title <br /> j., )L,:(, 1 0 : 3 0 QPM 0 PM <br /> e j,-" <br /> V�e nri�) A, lfar,;� Operational Status Tire Type Business Role Storage Type <br /> j (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 5 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> p-S Latitude 0 0 Closed 0 Altered 0 Hauler 0 indoor <br /> G 0 0 inactive 40 Truck 0 End-Use container <br /> Longitude 0 Planned 0 OTR <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer Q 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 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 <br /> m m "' <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle U) <br /> (Required for NOV or EXT) �R <br /> C� <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 /> 2 <br /> W <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 0 in Compliance-No Violations <br /> 0 0 1 Other:§ <br /> CommentsLL) -4y <br /> da Zt <br /> 411�� <br /> or's Signature�� <br /> Include <br /> Inspect <br /> ion Form 7d: 0 A—,440!—Zog_ <br /> 'mm <br /> ,7 Included: <br /> Comments Included: 0 Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> Phone <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: IEXAMPLE I 11 2 3 <br /> ■ <br /> MWhite Copy:CalRecycle Yellow Copy:operator Pink Copy:LEA <br />