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Waste Tire Su tey & Inspection Report <br />CalRecycle State of California <br />CalRecycle Recovery <br />y (Cal Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />0 + A _ 42 �r..e.. <br />inspection Report Number <br />11- 1255789 <br />BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPID -" 2 G3 _ Q ) <br />"1 ' J l 1 <br />Inspection Type (Fill one) <br />Site Suffix: <br />® Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Visit Q Other <br />Local tel_ <br />Identifier:—r5L <br />v1 l y-1 — `\ <br />Q CHP Q CalRecycle Q Complaint_ Q Educational <br />Business or Facility Name <br />vast; <br />Inspected By Inspector <br />Physical Addres <br />PRC § 42956 - Registration/Decal in Vehicle <br />—2)j-- <br />_�)I f_ Ti'v K <br />O <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />4*C L A <br />' 7J <br />7 <br />Inspection Date <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Time In Time Out <br />Business Rep Title <br />( i *0 AM y � : �y O AM <br />I ` Z t <br />Q't> C-%�� -QlxLf2u ' <br />O PM V PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Q <br />Tire Count (Whole/PTE) i �]J <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />1 T <br />40 Active <br />Q Closed <br />0 Passenger <br />Q Altered <br />0 Generator <br />Q Hauler <br />0 Outdoor <br />0 Indoor <br />o <br />GPS Latitude <br />Q Inactive <br />Q Truck <br />O <br />Longitude — <br />Q Planned <br />0 OTR <br />i 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 />Q Service Station Q Hauler Q Agriculture Q Shredder 4P 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 />O <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />O <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Q <br />O <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />O <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />O <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />O <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />O <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q <br />Q <br />Other: § <br />Comments <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 />Inspection Form Included: ��Actor's <br />Comments Included: Business Reps Signature Phone Number Signature Phone Number <br />}� 62081 <br />INSTRUCTIONS ON BACK Correct: Incorrect: ^C � EXAMPLE 1 2 3 <br />White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LFA <br />�0 <br />y <br />R! <br />T <br />fV <br />0 <br />f <br />f <br />Lu <br />0 <br />6 <br />r <br />