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Waste Tire &. vey & Inspection Report. Inspection Report Number ■ <br />CalRecycle State of California(I 1 - 1196632 <br />CalRecycle t8l (Rev. y(Cal Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Part A - Giirwav BLUE OR BLACK INK PEN <br />Business Profile <br />V <br />Inspection Details <br />HAULING AND MANIFEST REQUIREMENTS <br />TPID - <br />Site Suffix: ' � � � 5 <br />� 1 <br />Inspection Type (Fill one) <br />0 Routine Q Re -inspection Q Referral Q Observation <br />Local <br />Identifier: OCA CUA 4` <br />` <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint <br />Q Educational Visit Q Other <br />Business or Facility Name <br />PRC § 42956 - Registration/Decal in Vehicle <br />Inspected By Inspector <br />Q <br />YI( <br />Physical gess <br />Q <br />- <br />Q <br />' © ) m oss c�G I -c-_ r�1 <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 />L c„—� CAS <br />LS 3�U <br />Inspection Date <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Time In <br />Time Out <br />Business Rep Title <br />Q <br />0 AM <br />( • 5- s 0 PM <br />0 AM <br />® PM <br />_ <br />' <br />Operational Status <br />Tire Type <br />Business Role <br />Storage ype <br />Tire Count (Whole/PTE) <br />—7 <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />' <br />0 Active <br />Q Closed <br />Q Passenger <br />Q Altered <br />® Generator <br />Q Hauler <br />Outdoor <br />Q Indoor <br />O <br />��� Latitude <br />Q Inactive <br />4D Truck <br />Longitude - <br />0 <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair 6 Trucking Fleet <br />Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer Q Auto Body Q Car Dealer <br />Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler Q Agriculture <br />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 />1 Other: § <br />Comments <br />Inspection Form Included: <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 />® In Compliance - No Violations <br />Comments Included:""— <br />Business Rep's Signature Phone Number 1 pe tor's Si <br />INSTRUCTIONS ON BACK I Correct:* Incorrect:E X AMP <br />■ White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA <br />Phone Number <br />62081 <br />® ■ <br />Uj <br />W <br />