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r <br /> Waste Tire Su. ve & Inspection Repo A nspection Report Number <br /> Cal Rec cle State of California Y <br /> Y CalRecycle 18,1(Rev.10/10i(Cal Survey Form Page 1 I1 - 1230143 <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 � � � _ O l Inspection Type(Fill one) <br /> Site Suffix: ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ) Ch If Referral,choose referral type(Fill one) <br /> Identifier: �jUn�C9��lit - `j 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> S0'1 I 5 H(:) <br /> Physical Address l <br /> { <br /> CA ��33� <br /> Inspection Date C1 / �7 / 1 S`�/n► �- <br /> W� CLQ Time In Time Out 6 <br /> Business pffp t t vn� Tule ,.l ` AM l s (� /� AM <br /> lL2jJ� C_ PM <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 4P Generator 0 Ouyoor <br /> O 0 Closed 0 Altered 1�vI f <br /> GPS Latitude <br /> O 0 Inactive 0 Truck 0 Hauler 0 Indoor <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 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 49 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 Notice Of Violation 0 Extension <br /> 0 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 EXTJ N <br /> a <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 In Compliance-No Violations o <br /> 0 1 0 1 Other:§ <br /> — a <br /> Comments kra� N <br /> No ViM ly hon 3 t l- a kA4 a4 (O nCe-1 n <br /> Inspection Form Included: 0 G <br /> Comments Included:' �- <br /> Business Rep's Signaturh Pho"ne Number lnspec 's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: 7X*NJ] E X A L E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co :L <br />