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2 Waste Tire Survey & Inspection Report <br />CalRecycle state of California <br />CalRecycle (Rev. Recovery <br />Survey Form v Page 1 <br />Dept of Resources Recycling and Recovery (CalRecycle) <br />Part A - Survey <br />Business Profile Inspection Details <br />Inspection Report Number ■ <br />I1 - 1210298 <br />BLUE OR BLACK INK PEN <br />TPID - Inspection Type (Fill one) <br />Site Suffix: I fj O "1 ` i � 1 0 Routine 0 Re -inspection 0 Referral 0 Observation <br />Local ����� CNWI� If Referral, choose referral type (Fill one) <br />Identifier: 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name Inspected By <br />PC, -z- -1 ,i� 'S <br />Physical Address <br />Ga s Aj, <br />Business Rep <br />�� '�_, <br />Sic -aIvGn Aa <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />Longitude — <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair <br />Used Tire Dealer 0 Auto Body <br />0 Service Station 0 Hauler <br />6AL7 �!® <br />Title <br />VA6C." A(z_-� o nash, p <br />Inspection Date <br />Time In <br />& AM <br />QPM <br />Operational Status Tire Type <br />j (Fill one only) (Fill all that appl <br />%Z;I— 0 Active 0 Passenger <br />O 0 Closed 0 Altered <br />• O 0 Inactive 0 Truck <br />0 Planned 0 OTR <br />Trucking Fleet <br />0 Car Dealer <br />0 Agriculture <br />Government <br />0 Collection <br />0 Shredder <br />U Retreader <br />0 Crumb Rubber <br />0 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 />Business Role <br />0 <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 Generator <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 Hauler <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />14 CCR § 18459.1 -Tire Program ID Number from CalRecycle <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Other: § <br />Inspector <br />/ t :�' <br />Time Out <br />0 End -Use 10 Container <br />Dismantler ( ) Tire Derived Fuel <br />Inspection Form Included: U <br />Comments Included:U <br />Business Rep's Signa re Phone Number I s to S' nature <br />INSTRUCTIONS ON BACK I Correct:* Incorrect: E X A M P L E <br />■ White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA <br />Phone Number <br />62081 <br />© ■ <br />® AM <br />i 'as <br />QPM <br />Business Role <br />Storage Type <br />(Fill all that apply) <br />(Fill all that apply) <br />0 Generator <br />0 Outdoor <br />1141A <br />0 Hauler <br />0 Indoor <br />0 End -Use 10 Container <br />Dismantler ( ) Tire Derived Fuel <br />Inspection Form Included: U <br />Comments Included:U <br />Business Rep's Signa re Phone Number I s to S' nature <br />INSTRUCTIONS ON BACK I Correct:* Incorrect: E X A M P L E <br />■ White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA <br />Phone Number <br />62081 <br />© ■ <br />