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Oa Waste Tire Sui vey & Inspection Report Inspection Report Number <br /> CalRec cle State of California <br /> Y CalRecycle l$1(Rev.10/10) Survey Form - Page 1 11 - 1229949 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � O � � l 1 _ O � Inspection Type(Fill one) <br /> Site Suffix: O <br /> Routine Re-inspection Referral Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. S4-y-\ 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical A dres <br /> y �j Inspection Date <br /> C I 1 -5 <br /> �a" Time In lJ L Time Out✓ <br /> Business Rep Title ` 5 b * AM 1 . _Z , AM <br /> c- � M 1 0P 0P <br /> erational 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 /> f ' • Active • Passenger 9 Generator 40 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet >, Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> Uj <br /> W <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments 1, � �O_SV_� "maN.,re �� b ii <br /> c ` �neoP 1n C3VT <br /> P <br /> % n; —N d�r� <br /> o. <br /> Inspection Form Included: 0 goi �srm- //Y? 440k a�^Comments Included: - <br /> _ Business Rep's Signature Phone Number Inspec is Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: EXAMPLE 62081 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />