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i <br /> �I��U1w�/Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of CaIR�Yde CalRecycle 18'1(Rev.10/10) purvey Form - Page 1 [J�l - 1196421 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- QInspection lype(Fill one) <br /> Site Suffix: 3 �-� O - OLE, ®Routine Q Re-inspection O Referral O Observation <br /> Locals�h �� � � If Referral,choose referral type(Fill one) <br /> Identifier: O CHP O CalRecycle Q Complaint O Educational Visit 0 Other <br /> J <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address � C Q &A n 6treet <br /> Inspection Date r J I Q [LT;�] <br /> City State ZIP Code Time In Time Out _ <br /> Business Rep Title 0 AM Q AM <br /> [1.2] : O 0P M2_ ' ®PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (FII one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) ; �I= <br /> O Active O Pas§enger ® Generator Q Outdoor <br /> GPS Latitude i j I I ® Closed Q Altered O Hauler Q Indoor <br /> vV/� <br /> I 1 � 1 _ <br /> I -TCCC ���LLL 111 o Q Inactive Q Truck <br /> Longitude - I I I ( 4 C7 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 /> Q Service Station O Hauler Q Agriculture Q Shredder ® Other <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ''ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENT ' I It <br /> O O .O Notice'Of Violation -Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 1 <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Complience'Deadline . <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m I m m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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 O Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste The End-Use Facilities w <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O ®I7. <br /> n Compliance No Violation's o <br /> O O Other:§ J <br /> Commentsaca!,o_ — / \ c_ <br /> __!! •• -- r1vL- r 4cJ 7��'l+`� C /lips—i/ �i'►� a <br /> .�w[G(-_—/_� � ?�'S.—�.�i�!��►�t.t�_�-d_L_wl�r�r �c�c�varJ.� t.�_�rccn�...�7c� <br /> �� ' 1.75 3 k 4 d�t__cLaw <br /> Inspection Form Included: Q <br /> Comments Included: O ���ls'^=�W Cn'�ll�'l - _ S o?O4 -e-i ?6 <br /> 73 <br /> Business Rep's Signature Phone Numbe Inspector's Signa Phone Number <br /> „'•u 1 ;, t „ 62081 <br /> INSTRUCTIONS ON BACK Correct. I Incorrect ,� E X A M P L 2 3 <br /> White Copy aiR cle Yellow Copy:Operator Pink Copy:LEA <br />