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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1242514 <br /> CalRecycle le 781(Rev.10/10) <br /> yCal Survey Form - Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Surv✓� BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 IS T7 n 3 Inspection Type(Fill one) <br /> Site Suffix: ` dC ® Routine Q Re-inspection Q Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: S A-6 �O�q �� {1 0� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 L Inspected By Inspector <br /> Physical Address r <br /> W 5 - G` Do f'J 0 �1) <br /> Inspection Date 0 / U <br /> Time In Time Out _f <br /> Business Rep Title V AM AM <br /> 1 V U 0 PM L ( 3 0 O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> 3 <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger 0 Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - O Planned ® OTR O End-Use Q Container <br /> Business Type(Fill all that apply) jj <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 11- <br /> Q Service Station Q Hauler Q Agriculture Q Shredder • Other Tpp 1ILGa M144rnd1'X1cr <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 0 Extension <br /> Q O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date[11 <br /> / m / m <br /> 0 Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O O 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 /> Q Q Other:§ .^ <br /> Comments w�Sy�'iJc_ \S1�Q�'�`L��.(1J1_¢,.—�J.r-���15 l�G►'12, (t�.i�f/1 ��2 �, <br /> kQ W 0V t Jk 0, �-, <br /> N O NIIOIA'H mn U j WctAs L(Y)TOO, <br /> Inspection Form Included: Q �5 I _ <br /> Comments Included: ss Insp or's re Phone Number 1/ <br /> Busineep's Signature Phone Number Signatu <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: ( g EXAM L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: E <br />