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Waste Tire Survey & Inspection Repon <br />CalRecycle State of California <br />CalRecycle 181 (Rev. 10/10)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 - 1230326 <br />BLUE OR BLACK INK PEN <br />TPID - 1 , `S'j ^ © <br />f "q <br />Inspection Type (Fill one) <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />Site Suffix: l o� <br />• Routine Q Re -inspection <br />Q Referral <br />Q Observation <br />Local , <br />Identifier: �a(-� J 0,11A1 � � <br />l <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Business or Facility Name <br />Inspected By <br />Inspector <br />Q <br />E 1CUM�+���ir�,S C2�� 6. M -A "o� <br />3 - <br />Q <br />O <br />Physical Address J <br />(2 <br />O <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />l"J I, l .� 0,-)w <br />. ,, j��\ <br />® <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />-�A0e)VL+0-\ (A <br />Inspection Date / <br />3 <br />1 S <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Time In <br />Time Out <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Business Rep Title1 <br />0 ® AM <br />U <br />l <br />10 AM <br />QPM <br />001kMori; ' o C�c.�crul �mfn�,, � <br />QPM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />i Tire Count (Whole/PTE) 1 <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />ch <br />0 Active <br />® Passenger <br />® Generator <br />® Outdoor <br />Q Closed <br />Q Altered <br />Q Hauler <br />Q Indoor <br />Cies Latitude � <br />Q Inactive <br />Q Truck <br />O <br />Longitude — <br />Q Planned <br />Q OTR <br />O 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 />0 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection 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 />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 />O <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Q <br />O <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />® <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 <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 />Q <br />Q <br />Other: § <br />Comments 0 10 ,1 -DI . t _ 1 t._ _ I 12�11 ►r .I <br />W Ue 5 �0 eta <br />Su. C.4 rc,-s�11�S <br />Inspection Form Included: <br />Comments Included: <br />l (JAY (i <br />Phone Number <br />INSTRUCTIONS ON ACK Correct: Incorrect: �y <br />0 White Copy: CalRecycle Yellow Copy: Operator <br />4 ` <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date m / m / m <br />(Required for NOV or EXT) <br />Q Referred / CalRecycle Enforcement <br />In Compliance - No Violations <br />vt <br />6� 3)79 <br />Phone Number <br />CV <br />a <br />0 <br />w <br />62081 <br />® ■ <br />