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1-1.1-12 B.S.0.0-2 8. <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle Ca,Recyce 1811(.Rev.10/10) Surve Form - Pagel I1 -1176609 <br /> y <br /> Dept of Resources Recycling and Recovery(CatRecycle) i <br /> Part A-Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- T T- 2 Z Inspection Type(Fill one) <br /> Site Suffix: F/ 10 Q 'C� d ® Routine Q Re-inspection Q Referral Q Observation <br /> Local — If Referral,choose referral type(Fill one) <br /> Identifier. yL—�u rz Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> - <br /> Business or Facility Nam Inspected By Inspector <br /> 1-24i <br /> Phys•c AddTs ,?j y - I'/ / I I &£X-R.E/v <br /> Street �S/S �ros�c�a_r�r• I <br /> Inspection Date <br /> CA <br /> City State ZIP Code Time In Time Out <br /> Business Rep ^ Title 1 � O FM� ��3 S �PM <br /> iE <br /> I'I I _.___ __ _ T. . ., I Operational Status Tire Type Business Role Storage Type <br /> � I ' <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) f f, II i f <br /> _J I—.__l_ _J J Q Active Q Passenger Q Generator Q Outdoor <br /> ® Closed Q Altered <br /> GPS Latitude � • Q Hauler Q Indoor <br /> O Q Inactive Q 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 Q 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or Exr) 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 /> f <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ®In Compliance-No Violations o <br /> 101 Q 1 Other:§ <br /> Comments .04 <br /> Inspection Form Included: Q <br /> Comments Included: 40/si wJ <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> J � d <br /> INSTRUCTIONS ON BACK Correct to rrect: , EXAMPLEi23 62081, <br /> ■ White Copy:Cal e y Yellow Copy:Operator Pink Copy:LFA <br /> l i <br />