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Oa Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle state or Ce 1.8.1(R I 1 - 1230328 <br /> CalRecycle cover (CalRecycle) Survey <br /> 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- Q s-�I Inspection Type(Fill one) <br /> r7 <br /> Site Suffix: t `7 ! I g O 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local ^ /���uIf Referral,choose referral type(Fill one) <br /> Identifier: S AJuo � 1 L4)� l t,Cl�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> i <br /> v.[,Ve.nt e C e f(, Cafe <br /> Physical Address - CS Z )TTa <br /> 3�4 <br /> 5_WS Inspection Date 3 0 <br /> CA Time In Time Out <br /> Business Repc Title 0 AM �1 4 0 AM <br /> L"Sf'. ;,"kilo, �L -PJ' 1 ' 3 U O PM oc 1 a PM <br /> J. Ck&-c'vbww O W n <br /> Qr Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) )7 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger 1% Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <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 f 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 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 <br /> Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires �J <br /> Vj 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 MO <br /> / S <br /> Q 14 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 EXT) N <br /> Q Q 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 Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> Comments ' nwPll\L--w)w4e__� Cwn—All' S C4 4n A <br /> ILA LA� n yk1!tA <br /> 'See- <br /> Inspection <br /> ee Inspection Form Included: Q ✓ , <br /> Comments Included: n, -'J <br /> Business Rep's Signature Phone Number �ILnZt,=sSig�nature Phone Number <br /> INSTRUCTIONS ON BACK [Correct-I* Incorrect: EIXIAIMIPILIE1 1112 N 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />