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Waste Tire Survey & Inspection Repon Inspection Report Number <br />Cal Recycle State of California ■ <br />CalRecycle 181 (Rev. y (cal survey Form Page 1 11-1226523 <br />Dept. of Resources Recycling and Recovery (CalRecycle) _ <br />Part A - Survey - BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID - Lt Inspection Type (Fill one) <br />Site Suffix: , g Q Routine It Re -inspection Q Referral Q Observation <br />Local �,, If Referral, choose referral type (Fill one) <br />Identifier: �C(Lv�� �, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Business or Facility Name Inspected By Inspector <br />Physical Address <br />644 L : <br />&AV&�kV&YN <br />Business Rep <br />Tire Count (Whol <br />GPS Latitude <br />Longitude - <br />Business Type (Fill all that apply) <br />® New Tire Dealer Q Auto Repair <br />Q Used Tire Dealer Q Auto Body <br />Q Service Station Q Hauler <br />CA C <br />Title <br />> > 2 <br />G <br />Tire Type <br />Business Role <br />Storage Type <br />O <br />(Fill all that apply) <br />(Fill all that apply) <br />O <br />U Trucking Fleet <br />Q Car Dealer <br />Q Agriculture <br />Inspection Date /0 <br />Time In <br />/ ,;7'5- / L 1 <br />Time Out <br />® AM SAM <br />O -0 QPM 1 QPM <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 />it 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 <br />Q <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Government <br />Q Collection <br />Q Shredder <br />U Retreader U Dismantler <br />Q Crumb Rubber <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 />Tire Derived Fuel <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date/m/m <br />(Required for NOV or EXT) <br />Q Referred / CalRecycle Enforcement <br />In Compliance - No Violations <br />Inspection Form Included: <br />Comments Included:` ___UfZ-� <br />Busi ess Re 's Signature Ph ne Number I or' Si nature Phone Number <br />62081 <br />INSTRUCTIONS ON BACK Correct: * Incorrect: ( E X A M L 1 2 3 <br />White Copy: CalRecycle Yellow Copy: Operator Pink Copy: E ® ■ <br />ti <br />N <br />0 <br />i <br />f <br />Lu <br />