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Waste Tire Avey & Inspection Report <br />CalRecycle State of California <br />CalRecycle 181 (Rev. (Cal Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery(CalRecycle) <br />Survey <br />e - c"miga <br />Inspection Report Number <br />11- 1255803 <br />BLUE OR BLACK INK PEN <br />,Business Profile <br />Inspection Details <br />TPID -Inspection I <br />1 <br />Inspection Type (Fill one) <br />Site Suffix: <br />® Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Local <br />Identifier: -�Cao,o'ri <br />1 <br />Business or Facility Name <br />Inspected By Inspector <br />;FA Gino <br />Physical Address'(% <br />3 <br />Inspection Date <br />1C1 <br />Time In Time Out <br />Business Rep Title <br />5— 0 AM� AM <br />0 PM o PM <br />' A <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE)(Fill <br />one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />0 Active <br />Q Closed <br />40 Passenger <br />Q Altered <br />0 Generator <br />Q Hauler <br />0 Outdoor <br />Q Indoor <br />GPS Latitude <br />0 <br />Q Inactive <br />Q Truck <br />Longitude — <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />0 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 <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 />� 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 />QQ <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date FI Mm Mi(o <br />Q <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 EX7) <br />0 <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 />Q In Compliance - No Violations <br />Q <br />Q <br />Other: § <br />�.� <br />G�-G�[�C.f C�,yt•�_ <br />Comments <br />� ��_� _ �.j._„�. \ _ �� ^ <br />t <br />"u <br />Inspection Form Included: Q <br />Comments Included: <br />Business Rep's Signature Phone Number Inspector's Signature Phone Number <br />62081 <br />INSTRUCTIONS ON BACK <br />Correct: Incorrect: E X A P L 1 2 3 <br />0 White Copy: CalRecycle Yellow Copy: Operator Pink op <br />