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Waste Tire Su. ✓ey & Inspection Report <br />CalRecycle State w califomia <br />CalRecycle 181(Rev.10/10) <br />(Cal Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery(CalRecycle) <br />Sart A - Survey <br />Business Profile Inspection Details <br />Inspection Report Number ■ <br />I1 - 1196466 <br />BLUE OR BLACK INK PEN <br />- <br />Site I " 7 _ O Inspection Type (Fill one) <br />Site Suffix: / Ip jJ & Routine Q Re -inspection 0 Referral 0 Observation <br />Local <br />Identifier: <br />Business or Facility Name <br />3';.Vy\ '-\q <br />Physical Address <br />ll`� bo �31 <br />Business Rep <br />�AcoC .� �'-\ 1,\"C> <br />, \"O <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />Longitude <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair <br />0 Used Tire Dealer 0 Auto Body <br />0 Service Station 0 Hauler <br />If Referral, choose referral type (Fill one) <br />0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br />Inspected By Inspector <br />CSC �Svi Inspection Date <br />Time In <br />Title tl 1 s� 0 AM <br />PM <br />IDS <br />O <br />O <br />U Trucking Fleet <br />0 Car Dealer <br />0 Agriculture <br />U Government <br />0 Collection <br />0 Shredder <br />I S / 1 3 <br />Time Out C <br />SAM <br />® PM <br />Business Role Storage Type <br />(Fill all that apply) (Fill all that apply) <br />• Generator 0 Outdoor <br />0 Hauler 10 Indoor <br />0 End -Use 10 Container <br />U Retreader Dismantler U Tire Derived Fuel <br />0 Crumb Rubber <br />Other <br />Part <br />B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />Operational Status <br />Tire Type <br />(Fill one only) <br />(Fill ail that appl <br />Active <br />a Passenger <br />0 Closed <br />0 Altered <br />0 Inactive <br />• Truck <br />0 Planned <br />0 OTR <br />U Government <br />0 Collection <br />0 Shredder <br />I S / 1 3 <br />Time Out C <br />SAM <br />® PM <br />Business Role Storage Type <br />(Fill all that apply) (Fill all that apply) <br />• Generator 0 Outdoor <br />0 Hauler 10 Indoor <br />0 End -Use 10 Container <br />U Retreader Dismantler U Tire Derived Fuel <br />0 Crumb Rubber <br />Other <br />Part <br />B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />V <br />A HAULING AND MANIFEST REQUIREMENTS <br />0 Notice Of Violation Extension <br />0 <br />0 PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline <br />PRC § 42956 - Registration/Decal in Vehicle <br />00 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date Ffl/M/ <br />m <br />0 <br />0 14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />0 <br />0 14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />(Required for NOV or EXT) <br />0 <br />0 14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 10 114 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers I 10 Referred / CalRecycle Enforcement <br />0 0 14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />N <br />N <br />0 <br />W <br />0 0 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators I In Compliance - No Violations o <br />0 0 Other: § li <br />� <br />Comments � pv�er.V1i; WctS4_ O V\ o com� OVA %5 <br />Inspection Form Included: <br />Comments Included: <br />® INSTRUCTIONS <br />pv� +2�Y\ <br />'Z 3Zy 5 qj-1 _d 2c <br />ess ep's SI n e Phone Number Inspe or's Signature <br />�K Corre In rrect: K E X AMPLE 1112 3 <br />White ogy: Cal cycle Yellow Copy: Operator Pink Copy: LFA <br />Phone Number <br />62081 <br />