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Waste Tire Survey & Inspection Report Inspection Report Number <br />CalRec cle State of California <br />Y CalRecycle 181 (Rev. 10/10)Survey Form -Page 1 I1 1177768 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID - J ! Inspection Type (Fill one) <br />Site Suffix: /J 1 6 5 1 ® Routine Q Re -inspection Q Referral Q Observation <br />LocalC[J. �� C•L If Referral, choose referral type (Fill one) <br />Identifier: -..�-L.l� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Business or Facility Name Inspected By Inspector <br />vat - Te rA �����h � � _ <br />Physical Address <br />�I`i % L 0"" 1�� �i P":�" J <br />Inspection Date <br />Time In <br />Business Rep <br />r <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />Longitude <br />CA <br />Title <br />a'6dL-5 <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair ® Trucking Fleet <br />Q Used Tire Dealer Q Auto Body Q Car Dealer <br />Q Service Station Q Hauler Q Agriculture <br />U Government <br />Q Collection <br />Q Shredder <br />U Retreader <br />Q Crumb Rubber <br />Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />O AM <br />S <br />HAULING AND MANIFEST REQUIREMENTS <br />' <br />®PM <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Operational Status <br />Tire Type <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />(Fill one only) <br />(Fill all that appl <br />PRC § 42956 - Registration/Decal in Vehicle <br />® Active <br />O Passenger <br />O <br />Q Closed <br />O Altered <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Q Inactive <br />® Truck <br />O <br />O <br />O <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q Planned <br />O OTR <br />U Government <br />Q Collection <br />Q Shredder <br />U Retreader <br />Q Crumb Rubber <br />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 />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />O <br />O <br />PRC § 42956 - Registration/Decal in Vehicle <br />O <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 />Q <br />O <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />O <br />O <br />Other: § <br />Comments <br />Inspection Form Included: <br />Comments Included: <br />Business RLp's Signature Phone Number <br />INSTRUCTIONS ON BACK Correct: I& Incorrect: <br />■ White Copy: CalRecycle Yellow Copy: Operator <br />Pink <br />D 6 / / 3 <br />Time Out <br />Q AM <br />' oZ C) 0 PM <br />Business Role Storage Type <br />(Fill all that apply) (Fill all that apply) <br />® Generator • Outdoor <br />Q Hauler O Indoor <br />Q End -Use Q Container <br />Dismantler ( ) Tire Derived Fuel <br />ENFORCEMENT STATUS <br />Q Notice Of Violation O Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EX7) <br />O Referred / CalRecycle Enforcement <br />I@ In Compliance - No Violations <br />oVT -169-`1677 <br />Phone Number <br />62081 <br />S <br />N <br />0 <br />Lu <br />Lu <br />Dismantler ( ) Tire Derived Fuel <br />ENFORCEMENT STATUS <br />Q Notice Of Violation O Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EX7) <br />O Referred / CalRecycle Enforcement <br />I@ In Compliance - No Violations <br />oVT -169-`1677 <br />Phone Number <br />62081 <br />S <br />N <br />0 <br />Lu <br />Lu <br />