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Waste Tire Sur ,iey & Inspection ReporAnspection Report Number <br />State of California <br />CalRecycle 11 - 1245366 <br />Ccyclin and R (Rev. y (Cal Survey Form -Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Dom.-+ n - BLUE OR BLACK INK PEN <br />Business Profile <br />V <br />Inspection Details <br />HAULING AND MANIFEST REQUIREMENTS <br />TPID -Inspection <br />Site Suffix: b <br />$ 0 <br />Type (Fill one) <br />Q <br />1 <br />Q Routine • Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Local / / <br />Identifier: C-� <br />Q <br />V�� L -p VVI, <br />Q CHP Q CalRecycle Q Complaint <br />Q Educational Visit Q Other <br />Business or Facility Name <br />Q <br />Inspected By Inspector <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />` • \` <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Physical Address <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 />15 kC'v \_0 <br />r G <br />Inspection Date Q <br />Q <br />Q <br />`'� <br />Time In <br />Time Out <br />Business Rep <br />Title�` <br />O AM <br />' -3 <br />Q AM <br />�vvl\1 <br />� h <br />'"' <br />l J 0 PM <br />0 PM <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 />Q Active <br />0 Closed <br />Q Passenger <br />Q Altered <br />Q Generator <br />/" IA— <br />Q Hauler <br />Q O,utd or <br />,,("/0 <br />Q Indoor <br />0 <br />GPS Latitude <br />O <br />Q Inactive <br />Q Truck <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 <br />Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Used Tire Dealer Q Auto Body <br />Q Car Dealer Q Collection <br />Q Crumb Rubber <br />Q Service Station Q Hauler <br />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 />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 />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date m / m / m <br />(Required for NOV or EX7) <br />Q Referred / CalRecycle Enforcement <br />0 In Compliance - No Violations <br />Inspection Form Included: U <br />Comments Included: Q <br />Business Rep's Signature Phone Number Inspec is Signature <br />INSTRUCTIONS ON BACK Correct: Incorrect: �� NJ �JEJX A Mj P JLJEJ 1 2 3 <br />■ White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA <br />I- V% z8 <br />Phone Number <br />62081 <br />N <br />0 <br />w <br />