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Waste Tire Survey & Inspection Report <br />CalRecycle State of California <br />CalRecycle 181 (Rev. Recovery <br />Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />part A --Survey <br />Business Profile Inspection Details <br />Inspection Report Number ■ <br />11 -1226393 <br />BLUE OR BLACK INK PEN <br />TPID - <br />Inspection Type (Fill one) <br />A <br />Site Suffix: ' Ll 5 6 6 , Q <br />® Routine Q Re -inspection <br />Q Referral Q Observation <br />LocalIf <br />Identifier: "f7C{ct✓1v\- + <br />Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Business or Facility Name <br />Inspected By <br />Inspector <br />V O� ' 1 C y." <br />-9 <br />Q <br />Physical Address <br />1, t <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Q <br />_ <br />Inspection Date ,� <br />✓� <br />Q <br />Q <br />Time In <br />TimeOut <br />Business Rep Title <br />O AM <br />1 ® PM <br />O AM <br />tit C7 n O PM <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 />Q <br />Q <br />-- <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE)(Fill <br />! <br />0 <br />one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />/ <br />(a Active <br />Q Passenger <br />0 Generator <br />® Outdoor <br />o <br />GPS Latitude <br />Q Closed <br />Q Altered <br />Q Hauler <br />Q Indoor <br />Q Inactive <br />®Truck <br />o <br />Longitude — <br />Q Planned <br />Q OTR <br />0 End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair (a Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection <br />Q Crumb Rubber <br />Q Service Station Q Hauler Q Agriculture Q Shredder <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 />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 />Q <br />Q <br />Other: § <br />Comments <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem/M/m <br />(Required for NOV or EXT) <br />Q Referred / CalRecycle Enforcement <br />® In Compliance - No Violations <br />Inspection Form Included: Q <br />Comments Included. is <br />Businegiekep's Signature Phone Number I spe &K-Qdatuo Phone Number <br />`w <br />f <br />Lu <br />0 <br />