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Waste Tire SjWey & Inspection Repor <br />State of California <br />CalRecycle <br />CalRecycle 181 (Rev. (CalRecycle) <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 />I1 -1176672 <br />BLUE OR BLACK INK PEN <br />TPID -, Inspection Type (Fill one) <br />Site Suffix: f (� -7 y 9 © / ® Routine Q Re -inspection Q Referral Q Observation <br />Local ^ If Referral, choose referral type (Fill one) <br />Identifier: /amu' Q CHP Q C IR I (_') C Ii) Ed I V' ' O h <br />C{iy) 7--"— <br />Business or Facility Namz "e !G% <br />-/T, SA <br />oPhysical Address <br />L <br />O <br />Business Rep <br />es <br />Tire Count (Whole/PTE) <br />%ps Latitude <br />Longitude <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair <br />® Used Tire Dealer Q Auto Body <br />Q Service Station Q Hauler <br />Title <br />C%1N7L��— <br />Q Trucking Fleet <br />Q Car Dealer <br />Q Agriculture <br />O <br />a ecyce ompalnt ucationa Islt t er <br />Inspected By Inspector <br />Inspection Date / 0 <br />Time In Time Out <br />U Government U Retreader <br />Q Collection Q Crumb Rubber <br />Q Shredder Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />0 AM <br />HAULING AND MANIFEST REQUIREMENTS <br />0 AM <br />Q O ® PM <br />0 .2 J <br />S ® 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 />® Passenger <br />® Generator <br />® Outdoor <br />O Closed <br />Q Altered <br />Hal lie <br />0 Indoor <br />Q Inactive <br />Q Truck <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q Planned <br />Q OTR <br />0 End -Use <br />Q Container <br />U Government U Retreader <br />Q Collection Q Crumb Rubber <br />Q Shredder 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 />0 <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 />) <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />O <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 />0 <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 />Q <br />1 Other: § <br />Comments <br />Eill����r�Cl <br />Dismantler ( ) Tire Derived Fuel <br />Q Notice Of Violation 0 Extension <br />Compliance Deadline <br />Date m / 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: 'z�✓ �—�zr —�Z <br />Business Rep's Signature Ph Number Inspector's Signature Phone Number <br />INSTRUCTIONS ON BACK [Correct: 0 Incorrect: XX E X P E 11 2 3 62081 <br />White Copy: CalRecycle Yellow Copy: Operator Pi k Copy L <br />