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Waste Tire ey & Inspection Reporil. <br />State of <br />CalRecycle CalRecyclel1ia 181n(Rev.10/10) <br />Dept of Resources Recycling and Recovery (CalRecycle) Survey Form - Page 1 <br />Part A - SurvPv <br />Inspection Report Number ■ <br />I1 -1242547 <br />BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPID -Inspection <br />Site Suffix: �% Q S - �/ <br />Inspection Type (Fill one) <br />L l4 <br />91 Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Local <br />Identifier: SdLn V �u'1,,,+7 ,41 <br />Businessoror Facility Name <br />Inspected By Inspector <br />b ( e Sr- 1 \ e_ (40 I Ml l()tQ_ C, <br />Physical Address <br />Q - <br />;),a -OVA 0 - <br />S�oc aA °l S S LD <br />Inspection Date / V -7/ S <br />Time In Time Out <br />Business Rep Title <br />B AM I c 0 It AM <br />� I �� � <br />I -O 6%s�,���%.s Cos,-�f J��cr <br />O PM l v O PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) S <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />® Active <br />Q Closed <br />® Passenger <br />Q Altered <br />® Generator <br />Q Hauler <br />ID Outdoor <br />Q Indoor <br />GPS Latitude <br />Q Inactive <br />0 Truck <br />O <br />Longitude - <br />O Planned <br />® OTR <br />End -Use <br />Container <br />Business Type (Fill all that apply) Chf <br />Q New Tire Dealer 40 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer Q Auto Body O Car Dealer Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br />Part <br />B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />Q Notice Of Violation Q Extension <br />O <br />O <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />O <br />O <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline <br />O <br />O <br />PRC § 42956 - Registration/Decal in Vehicle <br />OO <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date FrI/m/M <br />O <br />O <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />O <br />O <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />(Required for NOV or EXT) <br />O <br />O <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />O <br />O <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q Referred / CalRecycle Enforcement <br />O <br />O <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />O <br />O <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />A In Compliance - No Violations <br />Q <br />Lo <br />Other: § <br />Comments <br />\O,n7��nh MU�n�'O.�'. <br />Inspection Form Included: Q <br />Comments Included: <br />Busin s ep's Si a 're Phone Number Ins a tor's Sig ture Phone Number <br />�( 62081 <br />INSTRUCTIONS ON ACK ��orrerct:le Incorrect: NJ E X A E 1 111213 <br />■ White Copy: CalRecycle Yellow Copy: Operator Pink Cop LF�4 © ■ <br />