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' Inspection Report Number <br />Waste Tire S�.� vey &Inspection Repor� � <br />cal Recycle State of California <br />CalRecycle 181 (Rev. <br />I 1- 1226568 <br />Dept. of Resources Recycling and Recovery (CalRecycle)MurveyForm - page 1 <br />)art A - Survey BLUE -OR BLACK INK PEN <br />Business Profile <br />Site- <br />ite Suffix: �Q <br />Operational Status <br />Tire Type <br />Local <br />Identifier: S (1k Y) (,1.q JA l f) <br />W <br />Business or Facility Name <br />(Fill all that apply) <br />Physical Address <br />(Fill all that apply) <br />MOD- �%(�MeF Ave-. <br />49 Passenger <br />(k (� CZA- <br />C � 159 3 � <br />Business Rep Title <br />Q Altered <br />1 (� j <br />re k\ '_ UlA-%[. o f kea ���n�, tIXGYIfq(1� <br />Tire Count (Whole/PTE) <br />' <br />O <br />GpS Latitude <br />O <br />Longitude — <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair 0 Trucking Fleet <br />Q Used Tire Dealer Q Auto Body Q Car Dealer <br />Q Service Station Q Hauler 3 Agriculture <br />Inspection Details <br />Inspection Type (Fill one) <br />• 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 />Inspected By Inspector <br />3R - 1d I awb <br />Inspection Date I, Q / a I l <br />Time In Time Out <br />PM PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />® Active <br />49 Passenger <br />® Generator <br />Q Outdoor <br />Q Closed <br />Q Altered <br />Q Hauler <br />0 Indoor <br />Q Inactive <br />9 Truck <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Q Government Q Retreader Q Dismantler Tire Derived Fuel <br />Q Collection Q Crumb Rubber <br />Q Shredder 0 Other MSL f �l u (,t�' L > <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 />L <br />Comments �!),l�9- ��SIG �S e. ► )1 xno, on1 1 <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXn <br />Q Referred / CalRecycle Enforcement <br />® In Compliance - No Violations <br />-- -- -- - �u U1 At4+pnS o I (A ( Qui A+ con C.Q rn <br />Inspection Form Included: Q f <br />91 •3c3T <br />Comments Included: 4y�_1 <br />:FKsiness ep's Signature Phone Number <br />INSTRUCTIONS ON BACK I Correct:* Incorrect: <br />White Copy: CalRecycle Yellow Copy: Operator <br />Pink <br />Phone Number <br />62081 <br />© ■ <br />