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0 Waste Tire Survey & Inspection Report <br />CalRecycle State of California <br />CalRecycle 18i (Rev.y (Cal Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Part A - Survev <br />Inspection Report Number <br />I1 - 1230309 <br />BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPID - � Q <br />Site Suffix: 1 � <br />Inspection Type (Fill one) <br />® Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Local <br />Identifier: �C� J�jtChu <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Business or Facility Name <br />PlAt- - <br />Inspected By Inspector <br />�,r <br />- <br />Physical Address <br />� C <br />cz>k or ry tf) <br />Inspection Date <br />.1 q <br />Time In Time Out <br />Business Rep Title <br />D d 0 AM S 0 AM <br />� <br />CO1 — ^ <br />K`V1nti Y(blli ri`� <br />®PM QPM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) f� T% <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />' ' •� I <br />® Active <br />Q Closed <br />® Passenger <br />Q Altered <br />® Generator <br />Q Hauler <br />® Outdoor <br />Q Indoor <br />O <br />�PS Latitude <br />Q Inactive <br />Q Truck <br />O <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 />® 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 <br />B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />Q Notice Of Violation Q Extension <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 />Compliance Deadline <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 />Date m / m / m <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 />(Required for NOV or EX7) <br />Q <br />0 <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 Referred / CalRecycle Enforcement <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 />® In Compliance - No Violations <br />Q <br />Q <br />1 Other: § <br />Comments n_ i <br />�C.Vt ki, r oL' U19 GS�G " 11 f c, 1 t� r� ��0 0.^ 1-}� h1 S Ot Ac" (4� <br />0<5 \J 101 ,T 1t 0 !' Ol COCLAS 0T( uf)c.e.ro <br />Inspection Form Included: Q <br />- <br />Comments Included:®CA� <br />%ie <br />Business Rep's Signature Phone Number Ins a toy's Signature Number <br />INSTRUCTIONS ON BACK Correct: 0 Incorrect: IEIXIAIM E 1 2 3 62081 <br />0 White Copy: CalRecycle Yellow Copy: Operator Pink Cop .LEA © 0 <br />