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Repo Report Number <br /> Waste Tire S�ey & Inspectionp � <br /> CalRecycle <br /> State of <br /> (Rev.10/10) I1 - 1230055 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Su rvey Form Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ii q Q Inspection Type(Fill one) <br /> j� <br /> Site Suffix: 1 ` 3 a i 5 ) 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local / I J If Referral,choose referral type(Fill one) <br /> Identifier: SaA �j u G, u 1 (��,t(� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> b � <br /> Business or Facility Name Inspected By Inspector <br /> SP CA l46 u j� _ j /� <br /> Physical Address 3 ( V , CS (�OTT(7 <br /> 1 ° I L,u- 6.uL ccn <br /> C/� �1saL(D <br /> - <br /> Inspection Date © l S <br /> L.off; <br /> Time In Time Out <br /> Business Rep Title i 0 r� f AM 1 J c 19 AM <br /> T ,/� 1 V V QPM l J QPM <br /> V Sov& 1 ` '1ns�tJ� Pf <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 /> 0 Active 0 Pas enger 0 Generator 0 Outdoor <br /> 0 IS Closed Q Al ere YV J J <br /> GPS Latitude 0 Hauler /1 0 Indoor <br /> 0 0 Inactive 0 Truck <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 0 Other N/A <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 /> 0 O <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 /> 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 /> 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 m <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 0 Other:§ _ <br /> Comments r_,n;kj,l V 'r <br /> On7 ►" I-& <br /> SUS p 0��/1 ' NU -V; unS gS ca r��s <br /> Nc �s = &\ �Sp <br /> 2 <br /> CIO Il Tp1D_ <br /> Inspection Form Included: 0 _ ► _ ��....��� <br /> Comments Included: 0 <br /> si ess Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: (� E X A M I L�E 1 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co y: ® 0 <br />