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Waste Tire Su. Bey & Inspection Report Inspection Report Number ■ <br />Cal Recycle State of California I 1 -1210 213 <br />Ccyclin andle R (Rev. y (CalRecycle)Survey <br />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 -Inspection � Inspection Type (Fill one) <br />Site Suffix: 32 <br />2 � 9 1 e • Routine Q Re -inspection Q Referral Q Observation <br />Local <br />Identifier: C T <br />If Referral, choose referral type (Fill one) <br />CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name <br />i <br />ENFORCEMENT STATUS <br />V <br />- <br />Inspected By Inspector <br />dA Q_\'1 s <br />Q Notice Of Violation Q Extension <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Physical Address <br />_ 0 1 <br />`TT u <br />2-ZII .) y Dc� <br />PRC § 42956 - Registration/Decal in Vehicle <br />S,cV �ov� C <br />S2� <br />Inspection Date <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date M/m/m <br />Q <br />Time In <br />Time Out <br />Business Rep TitleAA <br />Q <br />0 AM0 <br />� Z. 3 <br />AM <br />S <br />(Required for NOV or EXn <br />Q <br />QPM <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />� PM <br />— <br />Q <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE)/ <br />Q <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />® Active <br />0 Passenger <br />® Generator <br />0 Outdoor <br />GPS Latitude <br />O <br />Q Closed <br />Q Altered <br />Q Hauler <br />4111 Indoor <br />O <br />Q Inactive <br />Q Truck <br />Longitude - <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 Q Trucking Fleet <br />Q Government Q Retreader 0 Dismantler Q Tire <br />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 <br />B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />Q Notice Of Violation Q Extension <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 />Compliance Deadline <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date M/m/m <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 />(Required for NOV or EXn <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 Referred / CalRecycle Enforcement <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 />® In Compliance - No Violations <br />Q <br />Q <br />Other: § <br />Comments <br />Q QOV Ol.�b ' q W CA -S VX O <br />Inspection Form Included: Q i r <br />Comments Included: <br />Business Rep's Signature Phone Number <br />2dOf-VGg• 32-8`1 <br />Phone Number <br />INSTRUCTIONS ON BACK I Correct:* Incorrect: E X A M P L EI 1112[3 62081 <br />0 White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA ® ■ <br />Y <br />0 <br />f <br />W <br />