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Waste Tire Su, vey & Inspection Report Inspection Report Number ■ <br />CalRecycle Ca�Recyce'18 (Rev. 10/10)I1 - 12 3 0 2 5 6 <br />Dept of Resources Recycling and Recovery (CalRecycle) Survey Form — Page 1 <br />'art A - Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID - ' � � � � � � o � � Inspection Type (Fill one) Q Q <br />Site Suffix: Q <br />Routine Re -inspection Referral Observation <br />Local If Referral, choose referral type (Fill one) <br />Identifier. Co Vwk`/ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Business or Facility Name / jj Inspected By Inspector <br />t�A\ . 0\a -V )leeC' 1. U C3 12v� (oc o, a rnn� _ �l <br />Physical Address 3 p 1 0 /\AAT 1 ,V <br />4966 F,was��oscz �- <br />\ \\ <br />5tvG TO v, <br />V <br />of <br />ISr2IS <br />Inspection Date <br />1 2-/ <br />2 9 <br />I 1 <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Time In <br />Q <br />Time Out <br />Q <br />Business Rep <br />Title <br />Q <br />1 1 ' <br />1 (> <br />AM <br />b 0 PM <br />r <br />® AM <br />O PM <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />Q <br />1 <br />Q <br />l <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />- <br />Operational Status <br />TireType <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE)(Fill <br />Commentst <br />10 <br />one only) <br />0 Active <br />(Fill all that apply) <br />® Passenger <br />(Fill all that apply) <br />$ Generator <br />(Fill all that apply) <br />® Outdoor zY <br />GPS Latitude <br />O <br />Q Closed <br />Q Altered <br />Q Hauler <br />* Indoor 3 <br />_*���� <br />Q Inactive <br />& Truck <br />Longitude — <br />o <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair <br />i Trucking Fleet <br />Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer Q Auto Body <br />Q Car Dealer <br />Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler <br />Q Agriculture <br />Q Shredder Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A I <br />HAULING AND MANIFEST REQUIREMENTS <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q <br />Q <br />Other: § <br />Commentst <br />\c' <br />Inspection ncluded: Q <br />Inspection Form�nc <br />� <br />C nts luded <br />_*���� <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date m / Ffl / rfl <br />(Required for NOV or EXT) <br />Q Referred / CalRecycle Enforcement <br />*in Compliance - No Violations <br />kA <br />ommc <br />iness ep's Signature Phone Number Inspect 's Signature <br />INSTRUCTIONS ON BACK I Correct:* Incorrect: IEIXIAIMIPILIEI 1112 3 <br />0 White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA <br />cV <br />N <br />O <br />LU <br />LU <br />1— %&-3v <br />Phone Number <br />62081 <br />® ■ <br />