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02 Waste Tire Su. vey & Inspection Report Inspection Report Number ■ <br />Cal Rec cle State of California — <br />Y CalRecycle 181 (Rev. 10/10) Survey Form -Page 1 I1 1196462 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />r)--& A c....,.., BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPID -Inspection A U � � � � O � <br />Site Suffix: <br />Inspection Type (Fill one) <br />0 Routine 0 Re -inspection 0 Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />O CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br />Local <br />Identifier: b�� �uh�y <br />Business or Facility Name <br />«w,R_ V,sk�,�,�oV1 <br />Inspected By Inspector <br />Physical Address <br />3 9 - 1 0 <br />Way 300 <br />O <br />0 <br />SL � � <br />'Ccv� V\, <br />Inspection Date 1 c) 1 1 3 <br />1 `J <br />0 <br />Time In Time Out <br />Business Rep Title <br />' 0,M <br />o O AM <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />0 PM O PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <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 />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 Active <br />Q Passenger <br />* Generator <br />Q OutdI� <br />0 <br />GPS Latitude <br />0 Closed <br />0 Altered <br />0 Hauler <br />0 Indoor <br />0 <br />0 Inactive <br />0 Truck <br />Longitude - <br />O Planned <br />0 OTR <br />O End -Use <br />0 Container <br />Business Type (Fill all that apply) v4zkot <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 ��S e� ��V% <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />O <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />O <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />O <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />O <br />0 <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />O <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 />O <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />O <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />O <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />O <br />0 <br />Other: § <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Datem / m / m <br />(Required for NOV or EXT) <br />O Referred / CalRecycle Enforcement <br />0 In Compliance - No Violations <br />Comments N` WcLS- <br />'ri 1y�S C oy�r_ c!y, <br />�)o mN�� `CM5 <br />Inspection Form Included: 0 Y�- <br />Comments Included: 0 <br />Business Rep's Signature Phone Number Inspect is dignature Phone Number <br />INSTRUCTIONS ON BACK Correct: Incorrect: NJ E X A M P L E 1 2 3 62081 <br />White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA <br />N <br />0 <br />w <br />