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M Waste Tire Sup vey & Inspection Report Inspection Report Number <br />CalRecycle State of California 11 -1196605 <br />CalRecycle 181 (Rev. (Cal Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery(CalRecycle) <br />Part A - SIIrvP_v BLUE OR BLACK INK PEN <br />Business Profile <br />V <br />A <br />Inspection Details <br />TPID - O 5 1 - d <br />Site Suffix: ` <br />Inspection Type (Fill one) <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />0 Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Local \ <br />Identifier: SO -Y. �V') C0%3 <br />1 <br />/ <br />Business or Facility Name <br />Q <br />Q <br />Inspected By Inspector <br />a <br />\ <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Q <br />PhysicalAddress <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />� l <br />�j ` 1 M ;C l v <br />1°I 45 � �1�eh�y ave <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Inspection Date I 2 / ' g / 1 3 <br />Q <br />GS320 <br />010 <br />1 Other: § <br />Time In Time Out <br />Business Rep <br />Title <br />*AM _ 0 AM <br />1 �rntr�rw C t�lYl s h <br />�K C7�t h� <br />Q PM 40 PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) <br />%4 <br />"I <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />I* Active <br />Q Closed <br />Q Passenger <br />Q Altered <br />0 Generator <br />Q Hauler <br />0 Outdoor <br />Q Indoor <br />GPS Latitude <br />Q Inactive <br />Q Truck <br />Longitude - <br />O <br />Q Planned <br />0 OTR <br />Q End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />(76169,1 <br />Q New Tire Dealer Q Auto Repair <br />Q Trucking Fleet <br />Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer Q Auto Body <br />Q Car Dealer <br />Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler <br />Q Agriculture <br />\ <br />Q Shredder 0 Other �J ;Ay�SC <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 />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <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 />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 <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 />010 <br />1 Other: § <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem / m / m <br />(Required for NOV or EX7) <br />Q Referred / CalRecycle Enforcement <br />IS In Compliance - No Violations <br />Comments <br />`- <br />Inspection Form Included: U <br />Comments Include • <br />ksine"ss <br />��eeReg')gn�atulre Phon Number Inspec is Signature <br />INSTRUCTIONS ON BACK C rrect: 0 Incorrect: X NJ E X A M P L E 1 2 3 <br />■ White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA <br />-Y68-3Z8`1 <br />Phone Number <br />62081 <br />® ■ <br />a <br />(V <br />a <br />U) <br />0 <br />Lu <br />Lu <br />