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0 Waste Tire Survey & Inspection Report Inspection Report Number <br /> Cal Recycle t eof deli 8(Rev.10/10) _ i 11 - 1176758 - <br /> Dept of Resources Recycling and Recovery(CalRecycle) Survey Form Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- r I n Mot Inspection Type(Fill one) <br /> Site Suffix: I I6 ® Routine O Re-inspection'! O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. SU �C�e L�✓1� O CHP O CalRecycle O Complaint O Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Addre s LAY}� <br /> Street <br /> _ Inspection Date <br /> CA 376J Time In Time Out <br /> City State ZIP Cooe <br /> Business Rep Title 0 AM5 <br /> AM <br /> _ z 5 ® P13 <br /> M Z ®PM <br /> Operational Status Tire Type Business Role Storage Type <br /> I I I <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � <br /> five Pa <br /> r ® Generator O Outdoor AcO <br /> 0 sVIA- <br /> GPS <br /> I� <br /> GPS Latitude ® Closed O Altered <br /> O Hauler O Indoor <br /> O O Inactive O Truck <br /> Longitude - O Planned O OTR O End-Use O Container <br /> Business Type(Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder ® Other L/rA <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O Notice Of Violation O Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> O O 14 CCR§18459.1 Tire Program ID Number from CalRecycle 5 <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E)M N <br /> O 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 O Referred/CalRecycle Enforcement <br /> f - <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 1 O Other:§ L---- - —-- ----—--- —\ y—�--- <br /> Comments. ..T. T fGpa27=�—>re� 2\CLQ �'l�� �C.l .�—AL(/ili t am c� <br /> � t K.r111 � 7 <br /> Inspection Form Included: O <br /> � Comments Included: O — <br /> Business Rep's Signature Phone Number 1 sp ct s S' <br /> 1n ure Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Corre ncorrect: x d E X A L E 1 2 3 <br /> White Copy:Cal ec le Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> rj <br /> u ; <br />