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Waste Tire Sl,. vey & Inspection Reports Inspection Report Number <br />CalRecycle State of California 11 - 1245371 <br />CalRecycle 181 (Rev. (CalRecycle) <br />Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Part A - Survev BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPID - 1 <br />Site Suffix: 2 <br />Inspection Type (Fill one) <br />( <br />. Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Visit Q Other <br />Local �� <br />Identifier: 1� <br />v �`^ <br />Q CHP Q CalRecycle Q Complaint Q Educational <br />Business or Facility Name <br />Inspected By Inspector <br />lFse i3� �S <br />Physical Address <br />a <br />°� - AA7 <br />S'A5 IF, <br />Inspection Date <br />6 G / � S <br />v ` <br />Time In Time Out <br />Business Rep Title <br />� � D O QAM � � � 0 AM <br />* PM A PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />ID Outdoor i6l <br />0 Active <br />Q Closed <br />0 Passenger <br />Q Altered <br />40 Generator <br />Q Hauler <br />Indoor <br />O <br />GPS Latitude <br />Q Inactive <br />Q Truck <br />O <br />Longitude — <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />New Tire Dealer 4j Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br />Part <br />B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />Q Notice Of Violation Q Extension <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 />Compliance Deadline <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date M/M/m <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 />(Required for NOV or EXE <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 Referred / CalRecycle Enforcement <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 />• In Compliance - No Violations <br />Q <br />Q <br />Other: § <br />Comments <br />r g <br />xi v, -S 6c Aceas Cooxq^ <br />Inspection Form Included: Q <br />�( <br />Comments Included: <br />B ins Rep's Signature Phone Number Inspe or's Signature Phone Number <br />INSTRUCTIONS ON BA�K <br />Correct: Incorrect: <br />E�XJA�M�PJLJEJ 1 2 3 <br />62081 <br />0 <br />White Copy: CalRecycle Yellow Copy: Operator <br />Pink Copy: LEA <br />