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Waste Tire Su -1y & Inspection Reportftspection Report Number <br /> Cal Recycle State of California <br /> - 1.176417Caycling le 181(Rev.10/10) <br /> y(Cal Survey Form - Page 1 I1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ Inspection Type(Fill one) <br /> Site Suffix: 3 5 2 ) 2- `, ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: St>M ) �;, -,�� GA'-"k. Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name `n /�__(J� " ':1 Inspected By Inspector <br /> Physical Address nn <br /> � � i Z � ��Se w1 o hr I•�t)C- <br /> AA '' Inspection Date <br /> LANA <br /> `2 / ) / <br /> 'vlt�kCCACA T''37� T <br /> Time In Time Out <br /> Business Rep Title pO AM Q AM <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 /> 6 ® Active ® Passenger ® Generator ® Outdoor <br /> O <br /> GPS Latitude Q Closed Q Altered Q Hauler Q 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 /> ® New Tire Dealer ® 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 /> - --- -- -- - - -- 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 E)C7) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years W o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <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 •In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> Comments <br /> i <br /> Inspection Form Included: Q K <br /> Comments Included: ® - '� <br /> Business _ ig re Phone Number nspector's ignature hone Number <br /> INSTRUCTIONS ON BACK Cor Incorrect: E X A P L 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop �LEA <br />