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Waste Tire Survey & Inspection Report inspection Report Number ■ <br /> State of California <br /> CalRecycle 10/10) <br /> I 1 - 1242489 <br /> Ccyclin and <br /> (Rev.Recovery <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � O Inspection Type(Fill one) <br /> Site Suffix: ) ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ::—)un J O"Ut^ CO,NI^�j„ 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name L "� Inspected By Inspector <br /> E+(-) 12�ni Q _ <br /> Physical Address C \ 3 I i 0 1 r-s C 0-T-ro <br /> 1't O L . J A,(; �P\ P l. li <br /> S_ <br /> (,Fl Inspection Date <br /> _ <br /> J <br /> Time In Time Out <br /> Business Rep Title l l : V 0 19 AM AM <br /> "1 5� Q PM <br /> QPM pC.mu�� cr <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active 0 Passenger ®Generator o Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> 0 0 Inactive ® Truck <br /> Longitude - 0 Planned ® OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair ® Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 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 /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators le In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments <br /> 14_5I'- <br /> vi 'brns-01 u tis l+c0 n(ern_ <br /> Inspection Form Included: Q <br /> yO n <br /> Comments Included: -� 2, ��ure <br /> Business Rep's Signature Phone Number Ins tor's Signahone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X EXAM L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C py L ® ■ <br />