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Waste Tire SAey & Inspection Reporpinspection Report Number <br />Cal Rec cle State of California <br />Y CalRecycle 161 (Rev.y (Cal Survey Form - Page 1- I1 1245019 <br />Dept of Resources Recycling and Recovery (CalRecycle) <br />n--& A c....,..., BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPISite - 1 � O <br />Site Suffix: <br />Inspection Type (Fill one) <br />Q <br />Routine Re -inspection Referral Observation <br />0 p Q Q <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Local <br />Identifier: <br />Q <br />Q <br />Business or Facility Name <br />Inspected By Inspector <br />Physical Address "v\ e `er <br />4� - 1 C) 1 /\/j <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Inspection Date v 1 5 <br />1 <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Time In Time Out <br />Business Rep Title <br />110 AM 0 *AM <br />� PM � �-/ � O O PM <br />Q <br />Q <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Q <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 />n <br />Q Active <br />Q Passenger <br />Q Generator <br />Q Outdoor <br />Closed <br />Q Altered <br />'J <br />I'VA <br />Q Hauler <br />A /A <br />Q Indoor <br />GP$ Latitude <br />O <br />Q Inactive <br />Q TFuc1� <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 />Q Service Station Q Hauler Q Agriculture Q Shredder • Other M 0.�V\kv%rCe— <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 />Comments n <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date m / / m <br />(Required for NOV or EXT) <br />Q Referred / CalRecycle Enforcement <br />f In Compliance - No Violations <br />1 Q t <br />►� 1 (t,71t4Q-n 1 <br />Inspection Form Included: Q <br />Comments Included: Q ZSj& <br />Business Rep's Signature Phone Number Insp toy's Signature Phone Number <br />62081 <br />INSTRUCTIONS ON BACK Correct: 0 Incorrect: EXAMPLE 1 2 3 <br />White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LFA <br />N <br />0 <br />0 <br />w <br />w <br />