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Waste Tire Sup vey & Inspection ReporE <br />CalRecycle State of California <br />CalRecycle(Rev.Ho) Survey Form - Page I <br />Dept. of Resources Recycling anddRRecovery (CalRecycle) <br />Part A - Survey-_ <br />Business Profile Inspection Details <br />Inspection Report Number <br />I1 - 1242244 <br />BLUE OR BLACK INK PEN <br />TPID -Inspection '7� � m O ' Inspection Type (Fill one) <br />Site Suffix: 4D Routine Q Re -inspection Q Referral Q Observation <br />Local <br />Identifier. � <br />BaanJ as � v � r Co ,' - - <br />Business or Facility Name ` <br />��, ' c <br />Physical Address p� <br />�-1SZo S. 1����,��./ C�C\ <br />(A gS21� <br />Business Rep Title <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />Longitude - <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair <br />Q Used Tire Dealer Q Auto Body <br />Q Service Station Q Hauler <br />0 Trucking Fleet <br />Q Car Dealer <br />Q Agriculture <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle O Complaint Q Educational Visit O Other <br />Inspected By <br />Inspection Date a g / <br />Time In <br />1 1O AM <br />jo 9 PM <br />Government <br />Q Collection <br />Q Shredder <br />U Retreader <br />Q Crumb Rubber <br />Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />Operational Status <br />Tire Type <br />HAULING AND MANIFEST REQUIREMENTS <br />(Fill one only) <br />(Fill all that appl <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 Active <br />Q Passenger <br />O <br />Q Closed <br />Q Altered <br />O <br />Q Inactive <br />0 Truck <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q Planned <br />O OTR <br />Government <br />Q Collection <br />Q Shredder <br />U Retreader <br />Q Crumb Rubber <br />Q 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 />O <br />O <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />O <br />O <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />O <br />O <br />PRC § 42956 - Registration/Decal in Vehicle <br />O <br />O <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />O <br />O <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />O <br />O <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />O <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />O <br />O <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />O <br />O <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />O <br />O <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />010 <br />1 Other: § <br />Inspector <br />M�kTTv <br />05 / 1 <br />Time Out <br />O AM <br />(, 2 S . PM <br />Business Role Storage Type <br />(Fill all that apply) (Fill all that apply) <br />0 Generator 9 Outdoory <br />Q Hauler 10 Indoor 1 <br />Q End -Use 1 O Container 11 <br />Dismantler <br />Tire Derived Fuel i <br />I <br />ENFORCEMENT STATUS <br />O Notice Of Violation Q Extension <br />Compliance Deadline <br />Date[T] / m / m <br />(Required for NOV or EX7) <br />O Referred / CalRecycle Enforcement <br />S In Compliance - No Violations <br />Comments n 0 `v�� \�Sl`�� r2 M�sp-Cst���y� OYl2 (h✓\ T��S �0.� Qh <br />Inspection Form Included: <br />Comments Included: (♦ in - Z��y6� <br />sess Rep's Signature Phone Number Insp or's Signature Phone Number <br />N <br />0 <br />LU <br />LU <br />INSTRUCTIONS ON BACK Correct: 40 incorrect: <br />I E X A M P I L I E 1 1112 3 62081 <br />0 <br />White Copy: CalRecycle Yellow Copy: Operator <br />. Pink Copy: LFA <br />® <br />0 <br />N <br />0 <br />LU <br />LU <br />