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Waste Tire Su. rey & Inspection Report <br />State of California <br />CalRecycle <br />CalRecycle 181(Rev.10/10) <br />(Cal Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery(CalRecycle) <br />part A - Survey <br />Business Profile Inspection Details <br />Inspection Report Number <br />I1 -1196571 <br />BLUE OR BLACK INK PEN <br />TPID - O � Inspection Type (Fill one) <br />Site Suffix: 0 Routine 0 Re -inspection 0 Referral 0 Observation <br />Local If Referral, choose referral type (Fill one) <br />Identifier: Sb�� Grp J AY-\ � � 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name 1 Inspected By Inspector <br />Physical Address 1 <br />"ICt oo _07 --- - <br />Business Rep �A _ � <br />5d\r ! ' OK)Ii-`n <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />Longitude - <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair <br />Inspection Date ' / 3 Q / <br />Time In Time Out <br />Title <br />[� *AM <br />� � � O PM <br />C. F.O. <br />/ <br />Operational Status <br />Tire Type <br />1 <br />(Fill one only) <br />(Fill all that appl <br />l0 <br />Active <br />0 Closed <br />0 Passenger <br />0 Altered <br />0 <br />. <br />0 Inactive <br />0 Truck <br />O <br />0 Planned <br />0 OTR <br />Trucking Fleet 0 Government 0 Retreader <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br />0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br />0 AM <br />2 i PM <br />BusinessRole Storage Type <br />(Fill all that apply) (Fill all that apply) <br />0 Generator 0 Outdoor <br />0 Hauler 10 Indoor <br />0 End -Use 0 Container <br />Dismantler <br />0 Tire Derived Fuel <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility ENFORCEMENT STATUS <br />V A HAULING AND MANIFEST REQUIREMENTS <br />0 Notice Of Violation � Extension <br />O O <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 0 PRC § 42953 - Contracts with Registered Waste Tire Haulers. Compliance Deadline <br />PRC § 42956 - Registration/Decal in Vehicle <br />00 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements Date m / FF / m <br />0 0 14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />0 0 14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or t=XT) <br />0 0 14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 0 14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers 0 Referred / CalRecycle Enforcement <br />0 0 14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 0 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br />0 1 0 1 Other: § <br />Comments <br />Inspection Form Included: U <br />Comments Included: <br />■ INSTRUCTIONS ON <br />cos 5 <br />Phone Number Insp ctor <br />XK Correct: 0 Incorrect: IEIXIAIMIPILIEI 1112 3 <br />White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA <br />►9-322 4 <br />Phone Number <br />62081 <br />® ■ <br />