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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 11 - 1230338 <br /> CalRecycle d Recovery <br /> y(cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- rr Inspection Type(Fill one) <br /> Site Suffix: b • Routine Q Re-inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: Soto JOu- 01.t.fl Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 <br /> Inspected By Inspector <br /> Physical�� 3 Addresi - l 5 CO'T j�) <br /> `a a\S C _ <br /> C A 6C )L1 S Inspection Date 3 <br /> O Va^ J Time In Time Out <br /> Business Repo Title Q '1 0 AM 0 AM <br /> C'lii 5 � � S I, .{'lel' V PM ®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 /> Q Active Q Pass nger Q Generator Q Outdoor <br /> O f) Closed Q AlfereQ)A rj JJ <br /> GPS Latitude Q Hauler�i� Q I /V,/,d <br /> � <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q 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 0 Other '606 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 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 EX7) <br /> a <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance-No Violations o <br /> Q Q Other:§ l_ <br /> Comments 1 G ► IA1 (�� UlNli1 L014S fl �- N <br /> iA)"S 0,41nI,V-81�u,r C' 0j'A'_h'ff-,Z) L wn up t D, <br /> Inspection Form Included: Q <br /> Comments Included: Q �} $n - <br /> Business Rep's Signature Phone Number spe or's Signature Phone Number <br /> �( 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: W NJ EXAMPLE 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />