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Waste Tire Sup vey & Inspection Repor' L Inspection Report Number <br />State of California <br />CalRecycle 11 - 1245226 <br />CalRecycle (Rev. Recovery <br />Survey Form - Page I <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID -Inspection Type (Fill one) <br />Site Suffix: �� ? Q �i V I ® Routine Q Re -inspection Q Referral Q Observation <br />Local <br />Identifier: <br />Business or Facility Name ' <br />Physical Address <br />�90A-A'r,� <br />Business Rep <br />.PO 4S <br />Tire Count /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 />If Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Inspected By Inspector <br />Inspection Date C) g / <br />Time In V <br />Title <br />-\s/ j �Q AM <br />0PM <br />A <br />Operational Status <br />(Fill one only) <br />'® Active <br />Q Closed <br />Tire Type <br />(Fill all that appl <br />® Passenger <br />O Altered <br />4;— <br />' <br />O <br />. O <br />Q Inactive <br />O Truck <br />O <br />Q Planned <br />Q OTR <br />U Trucking Fleet <br />Q Car Dealer <br />Q Agriculture <br />U Government <br />Q Collection <br />Q Shredder <br />U Retreader <br />Q Crumb Rubber <br />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 />O <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />O <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />O <br />O <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <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 />O <br />O <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 <br />O <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />O <br />O <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 />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />010 <br />Other: § <br />Comments 1 <br />Inspection Form Included: O <br />Comments Included:® <br />Business Rep's Signature Phone Number <br />C) `s" / C �;' <br />Time Out <br />U <br />Q AM <br />—: 57 ® PM <br />Business Role Storage Type <br />(Fill all that apply) (Fill all that apply) <br />® Generator Q Outdoor <br />Q Hauler 141 Indoor <br />Q End -Use 10 Container <br />Dismantler ( ) Tire Derived Fuel <br />ENFORCEMENT STATUS <br />Q Notice Of Violation O Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXE <br />0 Referred / CalRecycle Enforcement <br />® In Compliance - No Violations <br />INSTRUCTIONS ON BACK [Correct: 0 Incorrect: ®� EXAMPLE I 1112 3 <br />0 White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA <br />c)y-f(Z-4 <br />Phone Number <br />0 <br />fV <br />a <br />0 <br />Lu <br />W <br />62081 <br />® ■ <br />