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Waste Tire4*ey & Inspection Replolnspection Report Number <br />CalRecycle State of California I -1176354 <br />CalRecycle 181 (Rev. y (CalRecycle)Survey <br />Survey Form - Page 1 <br />Dept, of Resources Recycling and Recovery (CalRecycle) <br />Part A - SurveyBLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID -Inspection Type (Fill one) <br />Site Suffix: �� y J t # Routine Q Re -inspection Q Referral Q Observation <br />Local`` -- If Referral, choose referral type (Fill one) <br />Identifier: ck t,. VA Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Business or Facility Name ((( Inspected By Inspector <br />Physical Address CI l <br />CA q5011-5- <br />Business <br />5011-5-Business Rep Title <br />i -u le webe✓ - Pze+ VIAT: n AG . <br />Tire Count (Whole/PTE) / <br />- O <br />GPS Latitude <br />O <br />Longitude — <br />Business Type (Fill all that apply) <br />C) New Tire Dealer Q Auto Repair <br />Q Used Tire Dealer Q Auto Body <br />Q Service Station Q Hauler <br />® Trucking Fleet <br />Q Car Dealer <br />Q Agriculture <br />Inspection Date % / 9,5 <br />/ t <br />Time In / Time Out <br />0 AM 6 AM <br />I Q Q a 0 PM C 3 0 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 />f Active <br />Q Passenger <br />® Generator <br />Q Outdoor <br />Q Closed <br />Q Altered <br />Q Hauler <br />AD Indoor <br />Q Inactive <br />• 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 />Q Retreader Q 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 />Inspection Form Included: (J <br />fig_ <br />Comments Included: <br />Business Rep's Signature Phone Number I p ct <br />INSTRUCTIONS ON BACK Correct:* Incorrect: E X A M <br />. White Copy: CalRecycle Yellow Copy: Operator Pink Cop . LEA <br />Q Tire Derived Fuel <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date m / m / m <br />(Required for NOV or EXT) <br />Q Referred / CalRecycle Enforcement <br />0 In Compliance - No Violations <br />=�16 0 L e 7 <br />Phone Number <br />3 62081 <br />© ■ <br />