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Waste Tire v fey & Inspection Repo r'11 <br />Inspection Report Number <br />CalRecycle State of California I 1- 1176578 <br />CalRecycle 181(Rev.10/10) <br />(Cal <br />Dept. of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br />Part A - Survev BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID -6 Z © ` Inspection Type (Fill one) <br />Site Suffix: l 1 ® Routine Q Re -inspection Q Referral Q Observation <br />Local- If Referral, choose referral type (Fill one) <br />Identifier: Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Business or Facility Nam J` Inspected By Inspector <br />Physical Address ,3 <br />3 n Z /v - rflu -okee to <br />Business Rep Title <br />I <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />Longitude — <br />Business Type (Fill all that apply) <br />® New Tire Dealer Q Auto Repair Q Trucking Fleet <br />® Used Tire Dealer Q Auto Body Q Car Dealer <br />Q Service Station Q Hauler Q Agriculture <br />Inspection Date / 1 Z ( / <br />Time In Time Out <br />Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <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 I A I HAULING AND MANIFEST REQUIREMENTS I <br />Q <br />0 AM <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 AM <br />I <br />S QPM <br />02 1 <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 />Q Closed <br />Q Altered <br />Q Hauler <br />Q Indoor <br />Q Inactive <br />Q Truck <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <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 I A I HAULING AND MANIFEST REQUIREMENTS I <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 />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem / M / m <br />(Required for NOV or EXT) <br />Q Q 14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers Q Referred / CalRecycle Enforcement <br />14 CCR 1 4 1 M f S R <br />ww <br />Q QV 8 6 - and est ystem equlremems for Waste The End -Use FaclhL es <br />Q Q 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />In Compliance - No Violations <br />Q Q Other: § -- < <br />Comments <br />Inspection Form Included: U e <br />Comments Included: <br />Business <br />INSTRUCTIONS ON BACK <br />Number <br />White Copy: CalRecycle Yellow Copy: Operator <br />CZ -0 Y40` 2 3 <br />�pector's Signature Phone Number <br />EXAPSE 123 <br />Pink C py: L A <br />