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y p pWaste Tire Surve & Inspection Re ortVlnspection Report Number <br />� <br />calRecycle State of California I 1 - 1242140 <br />CalRecycledR (Rev. Recovery <br />Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Part A - SIIrvP_v BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPID -Inspection <br />Type (Fill one) <br />Site Suffix: J 0 t <br />0 Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />LocalC e <br />Identifier: . (XA ��P1 �� CJ <br />_ll <br />Business or Facility Name <br />Inspected By Inspector <br />Physical Address <br />/6 Som IV, t'e A--_ <br />Inspection Date <br />l <br />�,—,/�p <br />� <br />" `gy <br />Time In Time Out <br />Business Rep Title <br />. O AM O AM <br />0 � � ®PM <br />'2- QPM ,� <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 />® Active <br />Q Closed <br />® Passenger <br />Q Altered <br />® Generator <br />Q Hauler <br />® Outdoor <br />Q Indoor <br />O <br />GPS Latitude <br />Q Inactive <br />® Truck <br />O <br />Longitude - <br />Q Planned <br />® OTR <br />Q End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair • 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 />V <br />A <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 or EX7) <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 />1010 <br />Other: § <br />Comments <br />ce-i Vl i2 <br />Inspection Form Included: Q <br />Comments Included: ® <br />OHI -130 - a - <br />Business Rep's Si nature Phone Number Ins a toy's• ig ture Phone Number <br />INSTRUCTIONS ON BACK Correct: 0 Incorrect: E X I A M P E 1 2 3 62081 <br />■ White Copy: CalRecycle Yellow Copy: Operator Pink Copy: L <br />