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1 <br />Waste Tire Survey & Inspection Report Inspection Report Number <br />CalRecycle State of California I 1-1226394 <br />CalRecycle cover (CalRecycle) <br />Survey Form - Page 1 <br />Dept of Resources Recycling and Recovery(CalRecycle) RI IIF (]R Rl_ACK INK PEN <br />'art A - 5ulyey .-------. — <br />Business Profile <br />Inspection Details - <br />Inspection Type (Fill one) <br />Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />TPID - r I �y <br />Site Suffix: b G l L/ <br />Local //,_� __ , <br />Identifier: ��/1� C45L Vi_j <br />Business or Facility Name <br />Inspected By Inspector <br />Physical Address <br />t <br />C'P_ _ 1 <br />�! s T ��CL• ✓ ��LJS C C- ' <br />Inspection Date / L <br />Time Out <br />Time In <br />Business Rep Title <br />O AM n O AM <br />6 0 PM wpm <br />4-�/� �i'n cin 2�.`S <br />Operational Status <br />(Fill one only) <br />— <br />Tire Type <br />(Fill all that apply) <br />Business Role <br />(Fill all that apply) <br />Storage Type <br />(Fill all that apply) <br />1 ✓1 <br />- <br />Tire Count (Whole/PTE) <br />41 Active <br />Q Passenger <br />®Generator <br />Q Outdoor <br />G FS Latitude <br />Q Closed <br />Q Altered <br />Q Hauler <br />Q Indoor <br />Q Inactive <br />® Truck <br />I <br />O <br />Longitude - <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 Q 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 />JJ �_--.� <br />Q Service Station Q Hauler Q Agriculture Q Shredder (J) Other ���I-i ��itA<4/ <br />Part <br />B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />HAULING AND MANIFEST REQUIREMENTS <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />V <br />A <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 />Compliance Deadline <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in' lehicle <br />QQ <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date m / m / m <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />(Required for NOV or EXl] <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 />O <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q Referred / CalRecycle Enforcement <br />Q <br />O <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />O <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />If In Compliance - No Violations <br />Q <br />1 Q <br />Other: § <br />Comments <br />Sea <br />Inspection Form Included: Q <br />s�� �y <br />- s- G�2 _g <br />Comments Included: <br />usiness ep's Signature Phone Number Si p to Si a re Phone Number <br />,)nai <br />INSTRUCTIONS ON BACK Correct:0 Incorrect: � 70 �% EXA�rl ■ White Copy: CalRecycle Yellow Copy: Operator Pink C <br />0 <br />IT <br />