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Oa Waste Tire Su, vey & Inspection Report 'inspection Report Number <br />CalRecycle State of California I 1 -1196379 <br />CalRecycle 181(Rev.(CalRecycle)Survey <br />Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Dart A - Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID - C6� O 1 Inspection Type (Fill one) <br />Site Suffix: J �j I e Routine Q Re -inspection Q Referral Q Observation <br />Local �. <br />Identifier: Scm r <br />J OU,(,11�,ln 1 (�U' -t� <br />Business or Facility Name ' <br />Physical Address <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 />3 1 - l 0 l G s 'ecro <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <br />Inspection Date I / <br />1 0 / <br />l 1 <br />I <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />Time In <br />Time Out <br />Q <br />Business Rep <br />Title0 <br />Q <br />®AM <br />I � � <br />®AM <br />� <br />f n <br />Q <br />Q <br />O PM <br />1 <br />O PM <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 />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) <br />Other: § <br />j <br />�9 <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />® Active <br />® Passenger <br />® Generator <br />& Outdoor <br />GPS Latitude <br />O <br />Q Closed <br />Q Altered <br />Q Hauler <br />Q Indoor <br />Q Inactive <br />Q 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 />Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />® 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 />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 1R okl� TS-- Vol (A,5tc. +> >(,- i nqczb Un <br />ENFORCEMENT STATUS <br />it Notice Of Violation Q Extension <br />Compliance Deadline <br />Date I C flq <br />(Required for NOV or EXn <br />Q Referred/ CalRecycle Enforcement <br />y <br />s. <br />LV <br />U) <br />0 <br />LU <br />LU <br />Q In Compliance - No Violations o <br />t 6 <br />AteJ eA in <br />Inspection Form Included: <br />Comments Included: • <br />Business Rep's ignature Phone Number Insp tor's Signature <br />INSTRUCTIONS ON BACK �Correct:* Incorrect:q EXAMPLE 1112 3 <br />■ White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA <br />Phone Number <br />62081 <br />® ■ <br />