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Waste Tire Su, Bey & Inspection Report Inspection Report Number <br />CalRec cle State of California — <br />Y CalRecycle 181 (Rev. 10/10) I1 1230386 <br />Form -Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle)Survey <br />Part A_- Survey ________ __ _ BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPID - � <br />Site Suffix: {` <br />Inspection Type (Fill one) <br />0 <br />• Routine 0 Re -inspection 0 Referral 0 Observation <br />If Referral, choose referral type (Fill one) <br />0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br />Local <br />Identifier:h C6 h <br />` , <br />Business or Facility Name <br />Inspected By Inspector <br />PRC § 42956 - Registration/Decal in Vehicle <br />ATeVu <br />Physical Address <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />lc��ct 13 c 4_' Xy`� "'�7 She-, X44 <br />0 <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />0 <br />Inspection Date <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Time In Time Out <br />Business Rep Title <br />0 AM 0 AM <br />' 2 <br />C�'o�r1tso Gev► . M <br />PM O PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />� <br />Tire Count (Whole/PTE) <br />(Fill one only) <br />• Active <br />(Fill all that apply) <br />0 Passenger <br />(Fill all that apply) <br />• Generator <br />(Fill all that apply) <br />0 Outdoor <br />0 Closed <br />0 Altered <br />A)1, y <br />0 <br />GPS Latitude <br />0 Hauler <br />0 Indoor <br />0 <br />0 Inactive <br />0 Truck <br />Longitude - <br />0 Planned <br />9 OTR <br />0 End -Use <br />0 Container <br />Business Type (Fill all that apply) t U - <br />A- <br />0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br />0 Service Station 0 Hauler 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 />0 <br />0 <br />Other: § <br />Comments <br />•.__ _. � -\_1` <br />Inspection Form Included: <br />Comments Included: <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 />Signature Phone Number <br />62081 <br />INSTRUCTIONS ON BACK Correct: I, Incorrect: E X A M P L E 1 2 3 <br />■ White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA © ■ <br />