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Waste Tire Survey & Inspection Report -Inspection Report Number ■ <br />State of California <br />CalRecycle I 1 -1226343 <br />Caycling and <br />(Rev. Recovery <br />Survey Form -Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile *� <br />Site Suffix: Q <br />Local 'S <br />Identifier: <br />Business or Facility Name <br />QOM <br />Physical Address <br />35 35 CAI Q_ <br />'Sk° &A v,\ GA SZ� <br />Business Rep "Title <br />l�Ul� n5 11C1ASgW�liln Sll�� <br />Tire Count (Whole/ TE) 5 <br />GPS Latitude <br />Longitude <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair ® Trucking Fleet <br />Q Used Tire Dealer Q Auto Body Q Car Dealer <br />Q Service Station Q Hauler Q Agriculture <br />U <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 />Inspected By Inspector <br />,� 9 - I o I estoh <br />Inspection Date 3 / 1 6 / 1 a <br />Time In I.� Time Out <br />1 Q PM 1 Q PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />IS Active <br />Q Passenger <br />Q Generator <br />Q Outdoor <br />Q Closed <br />Q Altered <br />Q Hauler <br />0 Indoor <br />Q Inactive <br />® Truck <br />O <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q Planned <br />® OTR <br />Q End -Use <br />Q Container <br />F,,W)'4 <br />Q Government <br />Q Retreader <br />Q Collection <br />Q Crumb Rubber <br />Q Shredder <br />Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <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 />O <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />O <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Q <br />O <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />O <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 <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 />Q <br />Q <br />Other: § <br />Comments e'b�j\.IASL. VJGVS C��l i(� �J n 15 pzjlU^aL O-` <br />Dismantler ( ) Tire Derived Fuel <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />Q Referred / CalRecycle Enforcement <br />In Compliance - No Violations <br />9 <br />j Mo 0l q ( w.S iTY <br />Inspection Form Included: U <br />Comments Included: <br />Busine 's S g ature Phone Number <br />INSTRUCTIONS ON BACK Correct:* Incorrect: X <br />■ White Copy: CalRecycle Yellow Copy: Operator <br />Pink Copy: <br />1R 7__'A 1'A!_ j " t' MO <br />.- <br />1PN©©© <br />a <br />N <br />N <br />a <br />0 <br />n <br />