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0 0 Waste Tire &.. vey & Inspection Report Inspection Report Number <br />CalRecycle State of California 1 1 -1177563 <br />CalRecycle (Rev. Recovery <br />Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Part A - Survpv BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPID - e? �l -�? <br />Site Suffix: <br />Inspection Type (Fill one) <br />V <br />it Routine Q Re -inspection Q Referral Q Observation <br />Local c _ `��L��✓ <br />Identifier: tit <br />If Referral, choose referral type (Fill one) <br />Q <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Business or Facility Name <br />Inspected By Inspector <br />Physical Address <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />q'50V6 <br />Inspection DateCA <br />Q <br />Time In Time Out <br />Business Rep Title <br />^7 ' O AM j� O AM <br />L� 0 0- ® PM I `l Q PM <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Tire Count (Whole/PTE) �f <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />Other: § <br />jo Active <br />Q Passenger <br />® Generator <br />® Outdoor <br />O <br />GPS Latitude <br />Q Closed <br />Q Altered <br />Q Hauler <br />Q Indoor <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 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 />,C0"Cc c� <br />Q Service Station Q Hauler Q Agriculture Q Shredder ® 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 />Comments <br />Inspection Form Included: <br />Comments Included:078L _ 973A�; — <br />��B_ s Rep's Signature . Phone Number <br />INSTRUCTIONS ON BACK Correct:* Incorrect: X <br />White Copy: CalRecycle Yellow Copy: Operator <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />Q Referred / CalRecycle Enforcement <br />®In Compliance - No Violations <br />ar-96-7.5 <br />Phone Number <br />62081 <br />