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Waste Tire Survey & Inspection Re orelnspection Report Number <br /> CalRec Recycle P p _ <br /> Y State of California I 1 1230298 <br /> Ccyclin andle R(Rev.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- 5 O 3 - 0 Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: Lkc. J x4CLI Lk) Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name "�\5 <br /> Inspected By Inspector <br /> Physical Address ` O ) c5cx -f 0 <br /> So i �� ct a� v <br /> Inspection Date <br /> Skd C `�SZ.°3 •� <br /> Time In Time Out <br /> Busin Rep (� ` Title l��cfo1l y 1 , 10 AM ' O AM <br /> (��� l.lA`D <br /> �l,yllJlf� O PM PM <br /> - $ - A�CA 5 ` 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 /> '10 ® Active ® Passenger 9 Generator Q Outdoor <br /> O Q Closed Q Altered N/A <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned OTR O 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 14�SO&CA <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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 / rfl <br /> / 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)CT) 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 In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments 1r ], ` <br /> 1'I�1G, ,r� ., A C1 _a„ Ain S i4a a I <br /> C1 _ <br /> U�, iyr6 0 <br /> Inspection Form Included: O p r� <br /> Comments Included: ® <br /> Business Rep's Signature Phone Number Insp c or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X NJ][ jjj EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />