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Waste Tire SG. vey & Inspection Report Inspection Report Number <br />CalRecycle State of California 11 - 1.2 4 5 0 5 7 <br />CalRecycle (Rev. Recovery <br />Survey Fora - Page 1 <br />Dept of Resources Recycling and Recovery (CalRecycle) <br />Part A - Survey_ BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID -� � � � O � Inspection Type (Fill one) <br />Site Suffix: -! • Routine Q Re -inspection Q Referral Q Observation <br />Local If Referral, choose referral type (Fill one) <br />Identifier: SC -'_Y\ )C>" �t �� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Business or Facility Name Inspected By Inspector <br />v, L <br />Physical Address <br />t ^ S 7O0G Inspection Date 071 Q � / <br />c ld 1/1 C u{ Ll l -S <br />Time In Time Out <br />Business Rep Title 0 AM 0 AM <br />��W�Operational <br />' ' !j <br />00 PM <br />a <br />S ® PM <br />Status <br />Tire Type <br />Business Role <br />Storage Type <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <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 />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />* Active <br />Q Closed <br />• Passenger <br />Q Altered <br />0 Generator <br />Q Hauler <br />0 Outdoor <br />Q Indoor <br />O <br />GPS Latitude <br />o <br />Q Inactive <br />Q Truck <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Longitude - <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />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 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 />• <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 ` A '1 ; rp <br />Inspection Form Included: Q c <br />Comments Included: 0--it <br />1 <br />V1 <br />Business pre hone Number <br />INSTRUCTIONS ON BACK Correct: Incorrect: � W <br />0 White Copy: CalRecycle Yellow Copy: Operator <br />N <br />ENFORCEMENT STATUS <br />*Notice Of Violation Q Extension <br />Compliance Deadline <br />Date ® / F(2]'� / <br />(Required for NOV or EXT) <br />Q Referred / CalRecycle Enforcement <br />Q In Compliance - No Violations <br />:S <br />Phone Number <br />N <br />0 <br />Lu <br />Lu <br />IEIXIAIMIPILIEI 1112 3 62081 <br />Pink Copy: LEA ® ■ <br />