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Waste Tire Sur vey & Inspection Report Inspection Report Number ■ <br />State of California <br />CalRecycle I 1- 1196280 <br />CalRecycle 181 (Rev. (Ca[ Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Dn.+ A - Qi RLUE OR RLACK INK PEN <br />Business Profile <br />V <br />Inspection Details <br />HAULING AND MANIFEST REQUIREMENTS <br />TPID - <br />0 <br />Inspection Type (Fill one) <br />0 <br />Site Suffix: i 3 <br />Zj l <br />0 Routine 0 Re -inspection 0 Referral 0 Observation <br />If Referral, choose referral type (Fill one) <br />Visit 0 Other <br />Local�` � ���` �� C✓ <br />Identifier: <br />PRC § 42956 - Registration/Decal in Vehicle <br />/ <br />0 CHP 0 CalRecycle 0 Complaint <br />0 Educational <br />Business or Facility Name <br />0 <br />Inspected By Inspector <br />0 <br />rl el 5 ilii �3,�nrtirl,-f�l� <br />�s <br />i <br />c <br />Physical Address <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 />Inspection Date / <br />I Z) j <br />L <br />�/� <br />CA A <br />_id� 5Z'6 <br />Time In <br />Time Out <br />Business Rep Title <br />O AM <br />O AM <br />.�� <br />1 ' D ® PM <br />02 ® PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />0 Active <br />®Closed <br />0 Passenger <br />0 Altered-- <br />0 Generator <br />0 Outdoor <br />A/1A <br />O <br />GPS Latitude <br />0 Hauler <br />0 Indoor <br />0 Inactive <br />0 Truck <br />Longitude — <br />O <br />0 Planned <br />0 OTR <br />0 End -Use <br />0 Container <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet <br />0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer <br />0 Collection 0 Crumb Rubber <br />0 Service Station 0 Hauler 0 Agriculture <br />0 Shredder 0 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 />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 />0 <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 />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Date m / <br />(Required for NOV or EXE <br />0 Referred / CalRecycle Enforcement <br />0 In Compliance - No Violations <br />Inspection Form Included: 0 <br />-1/2 <br />Comments Included: 06 <br />Business Rep's Signature Phone Number In p ctor Si r Phone Number <br />INSTRUCTIONS ON BACK Correct: 0 Incorrect: E X A 1112 3 62081 <br />■ White Copy: CalRecycle Yellow Copy: Operator Pink Cop c L ® . <br />1� <br />N <br />0 <br />f <br />f <br />Lu <br />