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Waste Tire Survey & Inspection Report Inspection Report Number <br />CalRecycle State of CalRecycle1iforni181 Rev. <br />10/10)11 -1196504 <br />Dept. of Resources Recycling and Recovery (CalRecycle) Survey Form - Page 1 <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID - <br />Site Suffix: <br />-723S�t2�pj <br />Local <br />Identifier. Q.r <br />Business or Facility Name <br />�/�1`Nlk-r— �_\ �C''rU <br />Physical Address <br />SA -o c\e-kov, <br />Business Rep <br />9"whe <br />Tire Count (Whole/PTE) <br />GpS Latitude <br />Longitude <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair <br />Q Used Tire Dealer Q Auto Body <br />Q Service Station Q Hauler <br />Inspection Type (Fill one) <br />40 Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CalRecyde Q Complaint Q Educational Visit Q Other <br />Inspected By Inspector <br />C }� <br />�SZa6 <br />Inspection Date <br />l /2- <br />3 / <br />1 3 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Time In <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Time Out <br />Q <br />Title <br />Q <br />5 <br />O O AM <br />O AM <br />�-- 5 <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Q <br />0 PM <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />Q <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />010j <br />0 Active <br />Q Closed <br />Q Passenger <br />Q Altered <br />* Generator <br />Q Hauler <br />* Outdoor <br />Q Indoor <br />O <br />o <br />Q Inactive <br />0 Truck <br />Q Planned <br />Q OTR <br />Q End -Use <br />• Container <br />• Trucking Fleet <br />Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q Car Dealer <br />Q Collection Q Crumb <br />Rubber <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 />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 />010j <br />Other: § <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EX7) <br />Q Referred / CalRecycle Enforcement <br />® In Compliance - No Violations <br />Comments <br />y �e avegam---- <br />0.v��- <br />v�cQ��l <br />Inspection Form Included: Q U 0 00 <br />Comments Included: V <br />Business Rep's S' nature Phone Number Inspe or's Signature Phone Number <br />INSTRUCTIONS ON BACK Correct:* Incorrect: 11�1 EXAMPLE 1 2 3 62081 <br />■ White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LFA ® ■ <br />LU <br />W <br />0 <br />