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Waste Tire ftey & Inspection Repo"Inspection Report Number ■ <br /> CalRecycle Cte of alRecyclelifornia 181(Rev.10/10) 1244929 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 I 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' 1 I � � - ® Inspection Type(Fill one) <br /> � <br /> Site Suffix: 1 l� ( 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local r--, I If Referral,choose referral type(Fill one) <br /> Identifier: �an Jou�u�� ��� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> S0�"t (1, f04le( s 3 - <br /> Physical Address o (-OTIC) <br /> Va��eJ o Cc�ttr�. - <br /> Inspection Date 1 l / , �, / , S <br /> �ce�L� CurnP C� �S231 <br /> Time In Time Out <br /> Business Rep Title O AMO AM <br /> 3 . l 50 PM S Q 9 PM <br /> Sat ah IC arc u�u er <br /> Operational Status Tire Type Business Role Storage Type <br /> n <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> XU <br /> i Active Q Passenger ® Generator ® Outdoor <br /> GPS Latitude 0 Closed Q Altered <br /> Q Hauler 0 Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair • 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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q 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 /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q ( 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EX7 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Q Q Other:§ 1 a <br /> Comments l+-r)5gAV=!N (L � C (a[.�,��A1)ck I,]. <br /> �L _. <br /> Inspection Form Included: Q UR <br /> ' 7 3 <br /> Comments Included: ® (�26 <br /> B es Rep's ignature Phone Number Insp c or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: E X I A M P I L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />