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Waste Tire Survey & Inspection Report <br />State of California <br />CalRecycle <br />CalRecycle 181 (Rev. (Cal Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery(CalRecycle) <br />Part A - Survey <br />Inspection Report Number ■ <br />I1 -1210511 <br />BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />TPID - O , ^ 9 _ 0 <br />Site Suffix: lJ� <br />Inspection Type (Fill one) <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />0 Routine Q Re -inspection <br />Q Referral <br />Q Observation <br />Local�— <br />Identifier: �__ a n Jom Ain Co uo <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint <br />Q Educational <br />Visit Q Other <br />Business or Facility Name <br />TI <br />Inspected By Inspector <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Q <br />Physical Address <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />S <br />O <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />O <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />�D � <br />Inspection Date ` Q / <br />1 (^ / <br />1 3 <br />() <br />Time In <br />Time Out <br />Business Rep Title <br />O AM <br />v <br />O AM <br />M 0�, b ova �� <br />(D PM <br />® PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />i T <br />Tire Count (Whole/PTE) t.� (� <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />® Active <br />Q Closed <br />® Passenger <br />Q Altered <br />® Generator <br />Q Hauler <br />® Outdoor <br />Q Indoor <br />o <br />GPS Latitude <br />Q Inactive <br />Q Truck <br />O <br />Longitude - <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q .Retreader Q Dismantler Q Tire Derived Fuel <br />® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection <br />Q Crumb Rubber <br />Q Service Station Q Hauler Q Agriculture Q Shredder 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 />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 />® <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Q <br />0 <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />® <br />O <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />O <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />O <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 />010 <br />1 Other: § <br />Comments /1 1� _ -- .�"- J _ ? ., _ _-- 1�- A <br />7 <br />ENFORCEMENT STATUS <br />® Notice Of Violation Q Extension <br />Compliance Deadline <br />Datet l M�� / Fi �] <br />(Required for NOV or EXT) <br />Q Referred / CalRecycle Enforcement <br />Q In Compliance - No Violations <br />Inspection Form Included: 0 L if l� G Q i <br />&A L.(k <br />Comments Included: - 7 - - <br />Rusin ss Rep's Signature Phone Number Ins, or's Signature <br />INSTRUCTIONS ON BACK I Correct: I. Incorrect: X� q I I E I X I A IM P E 1 2 3 <br />■ White Copy: CalRecycle Yellow Copy: Operator Pink Co L <br />-3N <br />Phone Number <br />