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Waste Tire Su. ,✓ey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle 11 - 1196522 <br /> CalRecycle let8l(Rev.10/10) <br /> y(Cal 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- 1 ` ® 1 _ ® Inspection Type(Fill one) <br /> Site Suffix: 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � y�� r^vim Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name "- OJT Inspected By Inspector <br /> n <br /> Physical Address <br /> 2 S S o <br /> Inspection Date 1 / I 6 / 1 3 <br /> Time In Time Out <br /> Business Rep Title l 0 AM 0 AM <br /> 46 PM 0 PM <br /> C <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Vl/hol /PTE) r (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' O 0 Active Q Passenger ID Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler &Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 9 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 <br /> 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 /> N <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <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 •In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments ,T- _�, � COv�`'n�e`. -\J� `�� �hSQ�'C�•OV� �.Cyy�e... �Y�, ,� <br /> Vbc2��o �S <br /> Inspection Form Included: Q /—�ignature Comments Included: ps Si nat Phone Number InspectorPhone Number <br /> INSTRUCTIONS ON BACK Correc . Incorrect: (XIAIMIPILIE1 1112 3 62081 <br /> White Copy:C Recycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />