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Waste Tire Su. ✓ey & Inspection Report Inspection Report Number <br />CalRecycle State of California I 1- 1177996 <br />CalRecycle 181(Rev.y(Ca] 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 -c S. / I Inspection Type (Fill one) <br />Site Suffix: J IWn ® Routine Q Re -inspection 0 Referral Q Observation <br />Local <br />Identifier: Q J 0 K <br />Business or Facility Name <br />ns <br />Physical Address <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Inspected ByInspector <br />-1 1 <br />—1 O C S Cho <br />0GL�� <br />C <br />�SZo(� <br />Inspection Date <br />/ <br />`� / <br />"4 <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Time In <br />PRC § 42956 - Registration/Decal in Vehicle <br />Time Out <br />Q <br />Business Rep <br />Title <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />O AM <br />Q <br />/j O AM <br />l� <br />R Lo Cre'I 1 <br />1 L ( <br />l'�(lV.''1c'rt��11� J �� <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 PM <br />Q <br />V ® PM <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) <br />Other: § <br />3 <br />(Fill one only) <br />® Active <br />(Fill all that apply) <br />Q Passenger <br />(Fill all that apply) <br />I* Generator <br />(Fill all that apply) <br />it Outdoor <br />GPS Latitude <br />O <br />Q Closed <br />Q Altered <br />Q Hauler <br />Q Indoor <br />Q Inactive <br />f Truck <br />Longitude — <br />O <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 <br />® Trucking Fleet <br />Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer Q Auto Body <br />Q Car Dealer <br />Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler <br />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 />I 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 t] .. , , a-1 _ - ... L A.. <br />Inspection Form Included: <br />Comments Included: <br />0 G-j'(Act�; Of c"_1QZA 5 of c,0 n Cer-n_, <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date m / m / m <br />(Required for NOV or EXn <br />Q Referred / CalRecycle Enforcement <br />® In Compliance - No Violations <br />Phone Number I_ns p rs Sign, <br />INSTRUCTIONS ON BACK I Correct: 0 Incorrect: rJ E FX f <br />0 White Copy: CalRecycle Yellow Copy: Operator Pink <br />a <br />`i69- 3 <br />Phone Number <br />62081 <br />® 0 <br />4 <br />m <br />iV <br />a <br />0 <br />uj <br />W <br />