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Waste Tire Sui vey & Inspection Report <br />CalRecycle State of California <br />CalRecycle 10/10) <br />Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Part A - Survey <br />Inspection Report Number <br />11 .-1210533 <br />BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID - Inspection Type (Fill one) <br />Site Suffix: I • _7 0 Routine 0 Re -inspection 0 Referral 0 Observation <br />Local C <br />Identifier:l Vi �OC.t� v �"1 �L/✓V <br />Business or Facility Name <br />Physical Address <br />Business Rep <br />Tire Count (Whole/PTE <br />GFS Latitude <br />Longitude <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair <br />0 Used Tire Dealer 0 Auto Body <br />0 Service Station 0 Hauler <br />6A a5;L-0_�, <br />Title <br />,-Soo <br />O <br />O <br />If Referral, choose referral type (Fill one) <br />0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br />Inspected By Inspector <br />3 1 O 1 i4r,,4'r1G U-4 <br />Inspection Date / o?- G / 1 <br />Time In Time Out <br />Q AM <br />' _ 10 & PM <br />Business Role Storage Type <br />(Fill all that apply) (Fill all that apply) <br />® Generator 0 Outdoor <br />0 Hauler 10 Indoor <br />0 End -Use 10 Container <br />0 Trucking Fleet <br />Q AM <br />t J <br />C� 0 PM <br />Operational Status <br />Tire Type <br />(Fill one only) <br />(Fill all that appl <br />® Active <br />0 Passenger <br />0 Closed <br />0 Altered <br />0 Inactive <br />0 Truck <br />0 Planned <br />0 OTR <br />Q AM <br />' _ 10 & PM <br />Business Role Storage Type <br />(Fill all that apply) (Fill all that apply) <br />® Generator 0 Outdoor <br />0 Hauler 10 Indoor <br />0 End -Use 10 Container <br />0 Trucking Fleet <br />0 Government. <br />0 Retreader <br />U Dismantler Tire Derived Fuel <br />0 Car Dealer <br />0 Collection <br />0 Crumb Rubber <br />0 <br />0 Agriculture <br />0 Shredder <br />0 Other <br />0 <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />-A- <br />HAULING AND MANIFEST REQUIREMENTS <br />0 <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />(a <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 <br />0 <br />Other: § <br />Comments <br />Inspection Form Included: U // Y6 _ 777 <br />/ <br />Comments Included: 0 41 (/�6NT <br />Business Rep's Signature Phone Number <br />INSTRUCTIONS ON BACK [Correct: Incorrect: X 4 qf <br />White Copy: CalRecycle Yellow Copy: Operator <br />Pink Copy: LEA <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Datem/m <br />(Required for NOV or EX7) <br />0 Referred / CalRecycle Enforcement <br />® In Compliance - No Violations <br />Phone Number <br />62081 <br />® ■ <br />