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Waste Tire Su. dey & Inspection Report <br />CalRecycle State of California <br />CalRecycle 181 (Rev. y (Ca[ Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Part A - Survey <br />Inspection ReportNumber <br />I1 - 1242150 <br />BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPID - O <br />Site Suffix: S �j g <br />Inspection Type (Fill one) <br />62081 <br />I& Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Visit Q Other <br />Local <br />Identifier: S <br />Ol \ <br />Q CHP Q CalRecycle Q Complaint Q Educational <br />Business or Facility Name <br />Inspected By Inspector <br />a' <br />1"l\ 1 ln0 Cel1nC . <br />Physical Address <br />"1 1 0 1 , v <br />y,CiCr � • tn�O.Y� t�(T <br />Inspection Date <br />Time In Time Out <br />Business Rep TitleO <br />AM�40 O AM <br />O S &PM <br />V1 l •QY�� <br />40 PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />P <br />Tire Count (Whole/PTE) b <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />0 Active <br />Q Closed <br />0 Passenger <br />Q Altered <br />0 Generator <br />Q Hauler <br />41 Outdoor <br />i <br />Q Indoor <br />Cies Latitude <br />Q Inactive <br />41 Truck <br />0 <br />Longitude — <br />Q Planned <br />Q OTR <br />Q End -Use <br />• Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q 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 0 Other 5IPV03�9-- Yc-rv_ <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 />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 />Date <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 EXT) <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 />O In Compliance - No Violations <br />Q <br />Q <br />Other: § <br />Commentst�_2- <br />rr�� <br />00117A <br />Inspection Form Included: Q <br />Inspection <br />/ 2a9- /a��-� I <br />Comments Included: <br />B i e s Rep jidnaturgrPhone Number Inspec is Signature Phone Number <br />OPO <br />INSTRUCTIONS OPOAC <br />Co ect: <br />Incorrect: � 7V�I <br />EXAMPLE 1112 3 <br />62081 <br />W ite Copy: CalRecycle <br />Yellow Copy: Operator <br />Pink Copy: LEA <br />Y <br />�y <br />