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02 Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle 10/10) <br /> I 1 - 1177843 <br /> CalRecycle 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- �7 - O Inspection Type(Fill one) <br /> Site Suffix: ( 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �jpin JoLL 1,r C�,I ,� 0 CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> SLA) �i sc�nSQ� i(�r�► 3 - v [ �L <br /> Physical Address <br /> '10 k b ' <br /> �5331� Inspection Date <br /> Loc�lnco(� �� <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> d� 3 `j B PM 0 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 /> B Active Q Passenger 0 Generator 0 Outdoor <br /> O 0 Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive 18 Truck <br /> Longitude - 0 Planned Q OTR 0 End-Use ® Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 <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 /> Q 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / M m N <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 1010 1 Other:§ <br /> Comments Q_ 1 1 on Awls <br /> a k N <br /> �u''C�1 n¢ u� �s c.!�,j. �(jtl ,bl� �i !�,,1 U ��(1 1 1�yU � (711� � <br /> o -o' o w n5 01 SeuS rn- <br /> Inspection Form Included: Q <br /> Comments Included: ® <br /> siness Rep's Kignature Phone Number Insp or's Signature Phone Number <br /> �( 62081 <br /> INSTRUCTIONS ON BACK Correct In rect: XA � NJ EXAMPLE 11123 <br /> White Copy:Cal ecycl/ Yellow Copy:Operator Pink Copy:LEA <br />