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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle I 1 - 1244925 <br /> Caycling le 181(Rev.y(CalRecycle) Survey <br /> 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 � ` � � Inspection Type(Fill one) <br /> D <br /> Site Suffix: l J j ® Routine Q Re-inspection Q Referral Q Observation <br /> Local1 If Referral,choose referral type(Fill one) <br /> Identifier: Jon��'� C�V►�11� O CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> (�Ae 1A :a <br /> Physical Address — t o <br /> 1 CA; C�Sa4-L Inspection Date <br /> L.. _' Time In Time Out <br /> Business Rep 1 Title I ( , 3 b 0 PM ' a, ' ' D 00 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I S (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger I* Generator Outdoor <br /> O 0 Closed O Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O 0 Inactive ® Truck <br /> Longitude — 0 Planned Q OTR O End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> ®New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Used Tire Dealer 0 Auto Body Q Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 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 /> Q Notice Of Violation Q Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q O 14 CCR§13459.1 -Tire Program ID Number from CalRecycle <br /> 0 O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXTJ <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> O Q Other:§ <br /> CommentsLAA&Qk� _(_�J` ns ► ^ r5 i(1 <br /> U� ; �UN_" <br /> No /4/1 b S l ck� C,U-Oe,tn. <br /> Inspection Form Included: 0 <br /> ,Zo/�'- �GB� ciaoF-31 <br /> Comments Included: - <br /> ess Rep's Signature Phone Number Insp or's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correct:* Incorrect: EXAMPLE 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />