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Waste Tire Sup vey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1210252 <br /> CalRecycle 781(Rev.y(Ca] 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- L Inspection Type(Fill one) <br /> Site Suffix: y a 6 3 { © ( ® Routine Q Re-inspection Q Referral Q Observation <br /> Local � ``� - If Referral,choose referral type(Fill one) <br /> Identifier: Xv%_ _'ICCtrt"1_,_ �GtM�' ''J Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l� / Inspected By Inspector <br /> Physical Address SOL © t 09/-'}-r!t_�LL—,4 <br /> 1.�"l 62- �1 cis v;✓t �-: <br /> Inspection Date /- / l <br /> Lcx.K� c� GA ct� 3 7 <br /> Time In Time Out <br /> Business Rep TitleL` O AM O AM <br /> �lL Z_ Go PM < <' 4D PM <br /> Il l r:,�l� �nc�� iG� �,l,,v�►z--- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) I (Fill one only) (FII all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ® Active ® Passenger ® Generator ® Outdoor <br /> D Q Closed Q Altered <br /> G pS Latitude 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 a 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 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years N <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 <br /> Inspection Form Included: Q G2 !04j <br /> Comments Included: ® <br /> Business Rep's Signature Phone Number ln`spRislKature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAMPLE i 31 <br /> 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink y L ® 0 <br />