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Waste Tire Survey & Inspection Report <br />State of California <br />CalRecycle <br />CalRecycle(Rev. (Cal Survey Form - Page 1 <br />Dept. of Resources Recycling anddRecovery (CalRecycle) <br />Part A - Survey <br />Inspection Report Number ■ <br />I1 - 1177506 <br />BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />Inspection Type (Fill one) <br />TPID - 1 o + e Q <br />Site Suffix: ` <br />X <br />® Routine Q Re -inspection Q Referral Q Observation <br />Local <br />Identifier: CC u.�J <br />Business Facility Name <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 />or <br />CScU� ec«n,\rr ks <br />3 <br />0n ,,n <br />� Physical Address <br />White Copy: CalRecycle <br />1 <br />V\0 S N) (Acte c l A-V C_ <br />Pink Co_ EA <br />�Seu�en °�S3�J <br />Inspection Date <br />_I <br />Time In Time Out <br />Business Rep Title <br />5 O AM r3 O AM <br />J � � <br />d��b�- �l� s �n c. <br />- <br />®PM ®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 />le <br />0 Active <br />Q Closed <br />Q Passenger <br />Q Altered <br />® Generator <br />Q Hauler <br />0 Outdoor <br />Q Indoor <br />O <br />GPS Latitude <br />Q Inactive <br />Q Truck <br />O <br />Longitude — <br />Q Planned <br />OTR <br />Q End -Use <br />Q Container <br />Business Type (Fill all that apply) f f liq <br />Q New Tire Dealer Q Auto Repair Q 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 I* Other <br />Part <br />B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />V I <br />A I <br />HAULING AND MANIFEST REQUIREMENTS <br />Q Notice Of Violation Q Extension <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 />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date <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 />(Required for NOV orExr) <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 />_ - <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />® In Compliance - No Violations <br />Q <br />1 Q <br />1 Other: § <br />)3 <br />Comments <br />1 ` 1 (J <br />QUIAi <br />11` <br />NoI�1, <br />` V o _j d L47 ups �f rn�Qu c�iJ uAts ro. <br />Inspection Form Included: Q/91 <br />_ — <br />o. A, <br />Comments Included: ® <br />Busi ess Reps igna re Phone Number Inspe or's Signature Phone Number <br />INSTRUCTIONS ON BACK <br />Correct:* <br />] <br />Incorrect:Zk <br />E <br />X <br />A <br />E I <br />1 112 <br />3 <br />62081 <br />White Copy: CalRecycle <br />Yellow Copy: Operator <br />Pink Co_ EA <br />