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Waste Tire Su. ,iey & Inspection Report Inspection Report Number <br />CalRecycle State of cle 181 (Rev. <br />R 1196488 <br />CalRecycle 181(Rev.y(Cal Survey Form - 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 - � � � Inspection Type (Fill one) <br />Site Suffix: `lb Routine Q Re -inspection Q Referral Q Observation <br />Local <br />Identifier:�Y_� Cc� �,3� <br />Business or Facility Name �Ovr r TOt�kd <br />Physical Address 1 <br />i6> 0 S6v�� M c� �Y\ <br />i�Nv%e C',� q 5330 <br />Business Rep Title <br />�v0A\0X �Cv—OC 1�Cr <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />0 <br />Longitude - <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 />3 ci - 1 c> 1 m. TY\j <br />Inspection Date <br />/ <br />J 0 <br />3 <br />Time In <br />Q <br />Time Out <br />Q <br />I ' <br />0 AM <br />S <br />0 AM <br />PM <br />Q <br />PM <br />Q <br />• <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />® Active <br />Q Passenger <br />4111 Generator <br />•' Outdoor <br />Q Closed <br />Q Altered <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />Q Hauler <br />Q Indoor <br />Q Inactive <br />0 Truck <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 40 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 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 />010 <br />Other: § <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />O Referred / CalRecycle Enforcement <br />In Compliance - No Violations <br />Comments Q -o cs'h &,_t es", <br />Inspection Form Included: O <br />Comments Included: <br />Business Rep's Signature <br />Phone Number <br />c <br />(` 2o1 jQ -32$ q <br />INSTRUCTIONS ON BACK Correct: 40 Incorrect: IEIXIAIMIPILIEI 1112 3 <br />0 White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA <br />Phone Number <br />62081 <br />® ■ <br />