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Waste Tire Sc ey & Inspection Reportelnspection Report Number <br />State of California <br />CalRecycle I 1 -1255839 <br />CalRecycle 181 (Rev. (Cal Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Part A - Sifrvpv BLUE OR BLACK INK PEN <br />Business Profile <br />V <br />A <br />Inspection Details <br />O <br />Site O - 1 r� <br />Site Suffix: / <br />/� _ <br />"� <br />, <br />Ins tjgn Type (Fill one) <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />O <br />O <br />PRC § 42956 - Registration/Decal in Vehicle <br />Routine Re -inspection O Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Local <br />Identifier: S� <br />Q <br />w <br />O <br />Q CHP Q CalRecycle Q Complaint <br />Q Educational Visit Q Other <br />Business or Facility Name <br />Inspected By Inspector <br />O <br />TysicalAddre s�5 <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />O <br />O <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />3110 Ali. � 1l SOy� V`) o >�/ <br />O <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />O <br />O <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />SAW—AAa v� <br />n <br />C <br />��2bS <br />Inspection Date c) <br />1 <br />Time In <br />Time Out <br />Business Rep <br />TitleI <br />& AM <br />nn <br />AM <br />� � � � <br />Tv "b� �� <br />Aom\ <br />v QPM <br />QPM <br />G,n 1 <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) <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 />O Altered <br />49 Generator <br />Q Hauler <br />a Outdoor <br />Q Indoor <br />�aP$ Latitude <br />0 <br />Q Inactive <br />Q Truck <br />Longitude — <br />Q Planned <br />Q OTR <br />O End -Use <br />O Container <br />Business Type (Fill all that apply) <br />New Tire Dealer Q Auto Repair <br />Q Trucking Fleet <br />Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Used Tire Dealer Q Auto Body <br />Q Car Dealer <br />Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler <br />Q Agriculture <br />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 />O <br />O <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />O <br />O <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />O <br />O <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />O <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />O <br />O <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />O <br />O <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />O <br />O <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />O <br />O <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />O <br />O <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />O <br />O <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />n <br />n <br />Other: § <br />Inspection Form Included: <br />■ <br />Comments Included: <br />INSTRUCTIONS ON BACK I Correct: I• In <br />C <br />Number <br />White Copy: CalRecycle Yellow Copy: Operator <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date m / m / m <br />(Required for NOV or EX7) <br />0 Referred / CalRecycle Enforcement <br />IN In Compliance - No Violations <br />T <br />Inspector's Signature <br />EXAMPLE 1 2 3 <br />Pink Copy: LEA <br />4 <br />(V <br />a <br />Lu <br />Lu <br />?4-M-32 � <br />Phone Number <br />62081 <br />© ■ <br />