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Oa Waste Tire Survey & Inspection Report Inspection Report Number <br />Cal Rec cle State of California <br />Y CalRecycle 161 (Rev. 10/10)Survey Form -Page 1 1 1230278 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />part A _ BLUE OR BLACK INK PEN <br />- Survey <br />Business Profile Inspection Details <br />Site Suffix: 1 <br />Local <br />Identifier: <br />Business or Facility Name <br />Q 9M <br />Physical Address <br />3 S3 (s M ? M)R_-_ CA-. <br />5�0 C-0-0 V\' <br />Business Rep Title <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />Longitude — <br />CA 9SZ16 <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 />� - 1 y d %oAT TQ <br />Inspection Date o 1 C S <br />Time In Time Out <br />0 A C 0 A <br />® PM '2-✓ Ab PM <br />Operational Status Tire Type <br />(Fill one only) (Fill all that app] <br />. Active Q Passenger <br />O <br />Q Closed Q Altered <br />O Q Inactive 0 Truck <br />Q Planned Q OTR <br />Business Role Storage Type <br />(Fill all that apply) (Fill all that apply) <br />Generator Q O/`u't� qr <br />Q Hauler Q Indoor <br />Q End -Use 10 Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair 0 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 />Q Service Station Q Hauler Q Agriculture 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 />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 />n <br />n <br />Other: § <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 />Comments <br />Inspection Form Included: UU ����_„ <br />Comments Included: <br />Business Rep's Signature Phone Number nsp tor's Signature Phone Number <br />INSTRUCTIONS ON BACK Correct: I* Incorrect: EXAMPLE 112 3 62081 <br />0 White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA ® ■ <br />Lu <br />Lu <br />