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Waste Tire Survey & Inspection Report <br />CalRecycle State of California <br />CalRe andle R (Rev. y (Cal Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Survey <br />A _ ci imzoxr <br />Inspection Report Number ■ <br />I1 -1196359 <br />BLUE OR BLACK INK PEN <br />Business Profile <br />V <br />A <br />Inspection Details <br />Q <br />Q <br />TPID - p <br />, <br />1 <br />1 <br />4 <br />Inspection Type (Fill one) <br />Q <br />Q <br />Site Suffix: D <br />Q <br />O <br />® Routine Q Re -inspection Q Referral <br />If Referral, choose referral type (Fill one) <br />Q Observation <br />Local <br />Identifier: Saiz r-, C0"' �1�� <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />141 <br />ll <br />Q <br />Q CHP Q CalRecycle Q Complaint <br />Q Educational <br />Visit Q Other <br />Business or Facility Name <br />Q <br />Q <br />Inspected By Inspector <br />Q <br />Q <br />PI) r" S�ec,1' <br />Scrvl <br />(_e,S <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q <br />Q <br />Physical Address <br />3 q - 1 (0 1 <br />G5�TTU <br />O&� <br />R C <br />` <br />Inspection Date <br />C) 3 <br />1 J <br />`� <br />Time In <br />Time Out <br />Business Rep <br />Title <br />p� O AM <br />� ' O <br />O AM <br />� <br />CL N U � �� <br />0 S _ munt,,w- <br />is PM <br />o PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />10 Active <br />Q Closed <br />Q Passenger <br />Q Altered <br />& Generator <br />Q Hauler <br />Q Outdoor <br />®Indoor <br />O <br />GP$ Latitude <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 />0 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 <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 />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 />Comments <br />u S n o'I ej <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date m / m / m <br />(Required for NOV or EXT) <br />Q Referred / CalRecycle Enforcement <br />® In Compliance - No Violations <br />v 1 <br />�Lo-v 11 v1.( ' boS co( cl_Iecus -of cx2n wn _ <br />Inspection Form Included: U <br />Comments Included: � � <br />40 ?Aq-9N3-u� I <br />BU=Wss ep sfgna ure Phone Number <br />INSTRUCTIONS ON BACK Correct:* Incorrect: <br />■ White Copy: CalRecycle Yellow Copy: Operator <br />Pink <br />'1J�-l�p <br />Phone Number <br />62081 <br />© ■ <br />y <br />0 <br />w <br />