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r <br />Waste Tire Su, Bey & Inspection Report <br />CalRecycle State of California <br />CalRecycle 181 (Rev.y (cal 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 1177658 <br />BLUE OR BLACK INK PEN <br />i <br />PID - Inspection Type (Fill one) <br />ite Suffix: ( % 6 l 3 Q Q Routine ® Re -inspection Q Referral Q Observation <br />Local <br />Identifier: <br />Business or Facility Name <br />(6,,k T,r-�-_krt 5 <br />Physical Address <br />35 b8 4 - V-1c,,,Opos� <br />Business Rep <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />Longitude <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair <br />Q Used Tire Dealer Q Auto Body <br />Q Service Station Q Hauler <br />c,A a5a1s <br />Title <br />t-rean S. <br />0 <br />O <br />U Trucking Fleet <br />Q Car Dealer <br />Q Agriculture <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 />lot <br />Inspection Date ! I <br />Time In <br />Time Out <br />O AM O AM <br />C) o ® PM 3 ® 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 />Q Active <br />® Passenger <br />IS Generator <br />® Outdoor <br />• 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 Retreader <br />Q Collection <br />Q Crumb Rubber <br />Q Shredder <br />® 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 />Inspection FormIncluded: O <br />Comments Included: <br />Business Rep's Signature Phone Number <br />INSTRUCTIONS ON BACK I Correct: Incorrect: <br />® White Copy: CalRecycle Yellow Copy: Operator <br />Pink <br />Dismantler U Tire Derived Fuel <br />dv�-., mac, CIce, v) -"p <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 />Phone Number <br />62081 <br />® ■ <br />All <br />S! <br />�o <br />fV <br />0 <br />W <br />W <br />