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Waste Tire Su. Bey & Inspection Report <br />CalRecycle State of California <br />CalRecycle R (Rev. y (Cal Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Part A - Survey <br />Business Profile Inspection Details <br />TPID - Inspection Type (Fill one) <br />Site Suffix: I v� I Li 1 Q Routine Re -inspection Q Referral Q Observation <br />LocalL � If Referral, choose referral type (Fill one) <br />Identifier:- �Lt ✓! Sf� tt �,wr Cov6t�j Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Business or Facility Name `/ Inspected By Inspector <br />n <br />f;y� <br />Physical Address — /-�/`J�✓ L <br />9,15- te, (f ho, / i r <br />:nspection Report Number <br />I1 - 1210550 <br />BLUE OR BLACK INK PEN <br />j ay <br />1 z -A+ry�' <br />V <br />6 <br />t <br />Inspection Date <br />f / <br />'L/ <br />3. <br />1 - <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />Time In <br />Q <br />Time Out <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Business Rep <br />Q <br />Tiitle� <br />Q <br />Q <br />O AM <br />PM <br />) <br />--� U <br />O AM <br />S jr <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />1 <br />_ <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 <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />r <br />° <br />® Active <br />® Passenger <br />® Generator <br />0 Outdoor <br />GPS Latitude <br />Q Closed <br />Q Altered <br />Q Hauler <br />Q Indoor <br />Q Inactive <br />Q Truck <br />Longitude <br />- <br />O <br />Q Planned <br />Q OTR <br />O End -Use <br />Q Container <br />Business Type (Fill all <br />that apply) <br />New Tire Dealer <br />® Auto Repair <br />Q Trucking Fleet <br />Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer <br />Q Auto Body <br />Q Car Dealer <br />Q Collection Q Crumb Rubber <br />Q Service Station <br />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 />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 <br />Inspection Form Included: <br />Comments Included: <br />■ INSTRUCTIONS ONxio <br />Kil!p� <br />ASigna Phone Number <br />rrect: 0 Incorrect:ZN <br />White Copy: CalRecycle Yellow Copy: Operator <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date / m / m <br />(Required for NOV or EX7) <br />Q Referred / CalRecycle Enforcement <br />® In Compliance - No Violations <br />Phone Number <br />< IA M PI L E 1 2 3 62081 <br />Pink Copy: LEA ® ■ <br />Y <br />t! <br />N <br />w <br />