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Oa Waste Tire Survey & Inspection Report 'Inspection Report NumberState of ia ■ <br /> CalRecycle CalRecycle 1181nTev.10/10) <br /> Dept of Resources Recycling and Recovery(CalRecycle) Su rvey Form Page 1 I 1 1210 416 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> I <br /> � � � <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local ` � 1 If Referral,choose referral type(Fill one) <br /> Identifier: (1 WLIJI 11 C0 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B Inspector <br /> P Y P <br /> MIkL �I M40T S eo I.nc _ 3q - [ v 1 <br /> Physical Address rSCo;TTU <br /> C �sInspection Date t� / / j 3 <br /> Z 1 S l� <br /> Time In Time Out <br /> Business Rep Title AM AM <br /> � PM � � � � � PM <br /> Ti rr CDO()S M ung <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> w (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J <br /> 0 Active 0 Passenger Jp Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned 9 OTR 0 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 • 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 /> 0 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 /> 00 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 EXE 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 /> 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 Other:§ <br /> CommentsL!`1 + ► N <br /> \-)(A!2 Y)oetA= <br /> Inspection Form Included: Q 9p <br /> Comments Included: P/ 9�O ­JA (2 -- -0— <br /> Business Rep's Signature Phone Number Ins tor's Signature Phone Numbbr <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X;AMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C y: F�4 ® ■ <br />