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Oa Waste Tire Survey & Inspection Report Inspection Report Number <br />CalRecycle State of California <br />(R I 1 -1177953 <br />CalRecycle 181(Rev.y(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 />TPID -o Inspection Type (Fill one) <br />Site Suffix: t� 4C l LC q © 1 (9 Routine Q Re -inspection Q Referral Q Observation <br />Local <br />Identifier. <br />Business or Facility Name <br />Qe &-)4"'_' <br />Physical Addre s <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 />3 '� - 10 t A,,2,,n 6U, <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 />Inspection Date <br />J 0 / <br />( <br />© I <br />z <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Time In <br />Q <br />Time Out <br />Q <br />Business Rep <br />Title <br />Q <br />:O <br />AM <br />PM <br />2 O AM <br />3 � 1 ®PM <br />Ja <br />r041;_7t® <br />_3 <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 />--- <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE)(Fill <br />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 />GPS Latitude <br />O <br />Q Closed <br />Q Altered <br />Q Hauler <br />Q Indoor <br />Q Inactive <br />Q Truck <br />Longitude - <br />O <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />® New Tire Dealer ® Auto Repair <br />Q Trucking Fleet <br />Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer Q Auto Body <br />Q Car Dealer <br />Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler <br />Q Agriculture <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 />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 Form Included: Q l7 l �/ <br />Comments Included: ® <br />sines Rep's Signature Phone Number <br />INSTRUCTIONS ON BACK Correct: Incorrect: XOYI <br />White Copy: CalRecycle Yellow Copy: Operator <br />Pink <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem/M/m <br />(Required for NOV or EX7) <br />Q Referred / CalRecycle Enforcement <br />In Compliance - No Violations <br />r - `-roo - 74c> 4.' <br />Phone Number <br />62081 <br />