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M Waste Tire S0vey & Inspection ReporGInspection Report Number <br />cal Recycle State of California I 1 -1176568 <br />CalRecycle 181 (Rev. (Cal Survey Form -Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Part A - Survey_ _ BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />Site - Inspection Type (Fill one) <br />Site Suffix: E Z' �{ Y �% 0 Routine 0 Re -inspection 0 Referral 0 Observation <br />Local If Referral, choose referral type (Fill one) <br />Identifier: 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name Inspected By Inspector <br />06ys <br />Physic- 1 / <br />PhysicalCAdss dre0 901�OL„r) 8 N <br />GA <br />Business Rep Title <br />- Crcz �csv� r'uq r - <br />Tire Count (Whole/PTE) r 3 <br />— O <br />GPS Latitude <br />Longitude - <br />Business Type (Fill all that apply) <br />® New Tire Dealer ® Auto Repair <br />0 Used Tire Dealer 0 Auto Body <br />0 Service Station 0 Hauler <br />M <br />Inspection Date I 0 <br />Time In Time Out <br />0 <br />.� SAM <br />A <br />Q PM <br />Operational Status <br />Tire Type <br />(Fill one only) <br />0 <br />(Fill all that apply) <br />® Active <br />0 <br />10 Passenger <br />0 Closed <br />0 <br />0 Altered <br />0 Inactive <br />0 <br />0 Truck <br />0 Planned <br />0 <br />0 OTR <br />SAM <br />Q PM <br />Business Role Storage Type <br />(Fill all that apply) (Fill all that apply) <br />0 Generator * Outdoor <br />0 Hauler 10 Indoor <br />0 End -Use 10 Container <br />0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br />0 Car Dealer 0 Collection 0 Crumb Rubber <br />0 Agriculture 0 Shredder 0 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 />0 <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />010 <br />1 Other: § <br />Comments <br />1,44(7 Ad IQ And <br />Inspection Form Included: 01 f <br />Comments Included: <br />Phone Number <br />INSTRUCTIONS ON BACK�Correct:40 Incorrect: <br />White Copy: CalRecycle Yellow Copy: Operator <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Date m / m / m <br />(Required for NOV or EXT) <br />0 Referred / CalRecycle Enforcement <br />® In Compliance- No Violations <br />Cz�)yt.;?-ob <br />Phone Number <br />E X A M P E 1 2 3 62081 <br />Pink Copy: EA <br />r <br />0 <br />f <br />f <br />W <br />