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Waste Tire Stey & Inspection Repo Inspection Report Number <br />® CalRecycle CalRecyclel'ia 181n(Rev.10/10)11 -12 2 6 3 9 9 <br />Dept. of Resources Recycling and Recovery (CalRecycle) Survey Form Page 1 <br />BLUE OR BLACK INK PEN <br />Part A - Surve <br />Business Profile <br />- <br />Inspection Details <br />TPID -Inspection <br />Site Suffix: \ - ® <br />Type (Fill one) <br />® Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Q Other <br />Locall <br />CIO <br />Identifier: �� V U�"� li�� n 0 <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit <br />Business or Facility Name <br />v e L _ Cok o- �� <br />Inspected By Inspector <br />3 - 1 C� <br />Physical Address <br />0M Ill, Nw .c1l <br />.A\- 1 A <br />Inspection Date J__, <br />Time Out <br />Time In <br />Business Rep Title <br />: VO AM (� O AM <br />2j: V ® PM �} O ® PM <br />Operational Status <br />(Fill one only) <br />Tire Type <br />(Fill all that apply) <br />Business Role <br />(Fill all that apply) <br />Storage Type <br />(Fill all that apply) <br />%� <br />Tire Count (Whole/PTE) 1J <br />Q Active <br />Q Pasenger <br />Q Generator <br />Q Outdoor <br />®Closed <br />Q Alter 121 <br />0 Aq <br />Q Hauler <br />' y�4 <br />Q Indoor <br />O <br />GPS 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 i Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q 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 />Q Notice Of Violation Q Extension <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 />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 / <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />(Required for NOV or EX7J <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 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 />010 <br />Other: § <br />Comments <br />1- l <br />�D1A tAA, l \ <br />:> <br />S <br />�N �LtS <br />0 �,i 0 i v S <br />Inspection Form Included: O �I <br />"' <br />Comments Included: Q <br />Business Rep's Signature Phone Number Inspec o s Signature Phone Number <br />62081 <br />INSTRUCTIONS ON BACK Correct: ® Incorrect: E X AM L 1 2 3 ,-� <br />® White Copy: CalRecycle Yellow Copy: Operator Pink CopV <br />p <br />