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Waste Tire St...vey & Inspection Repor <br />State of California <br />CalRecycle <br />CalRecycle 181 (Rev. (Cal Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Part A -Survey__ <br />RucinPss PrnfilP ( IhsDection Details <br />TPID - (� <br />Site Suffix: i C� q -3 <br />Local ` Jdl ��­C�L <br />Identifier: C'l,l�, �, 1 L., <br />Business or Facility Name <br />Gfz,- -- c_3et l �) Q",-3 S <br />Physical Address <br />11193 fIC_)l ,I-r-C� <br />Business Rep <br />Tire Count (Whole/PTE) <br />GP$ Latitude <br />Longitude <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair <br />Q Used Tire Dealer Q Auto Body <br />Q Service Station Q Hauler <br />CA X06 <br />Title <br />0ic4my�' <br />_ t (,v" <br />Q Trucking Fleet <br />Q Car Dealer <br />Q Agriculture <br />Inspection Report Number ■ <br />I1 -1176779 <br />BLUE OR BLACK INK PEN <br />Inspection Type (Fill one) <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 />Inspected By Inspector <br />3 q - ) 0 ( Alam b u1c."_ <br />Inspection Date 9 15— <br />Time <br />5 <br />Time In Time Out <br />0 AM 0 AM <br />® PM �"i O p PM <br />v� <br />Tire Type <br />O <br />Storage Type <br />O <br />Q Trucking Fleet <br />Q Car Dealer <br />Q Agriculture <br />Inspection Report Number ■ <br />I1 -1176779 <br />BLUE OR BLACK INK PEN <br />Inspection Type (Fill one) <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 />Inspected By Inspector <br />3 q - ) 0 ( Alam b u1c."_ <br />Inspection Date 9 15— <br />Time <br />5 <br />Time In Time Out <br />0 AM 0 AM <br />® PM �"i O p PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />® Active <br />Q Passenger <br />f) Generator <br />® Outdoor <br />Q Closed <br />Q Altered <br />Q Hauler <br />Q Indoor <br />Q Inactive <br />® Truck <br />Q <br />Q <br />Q Planned <br />a OTR <br />Q End -Use <br />Q Container <br />Q Government () Retreader U Dismantler U Tire Derived Fuel <br />Q Collection Q Crumb Rubber Lxc✓tti�Cce V'f[�(�/12�, <br />� <br />Q Shredder ® Other P&��-soiil�j'&-S y &'tz � <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 />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 />Q <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 <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 />n <br />n <br />Other: § <br />Comments <br />Inspection Form Included: U1 <br />Comments Included: ® —ZCR - <br />I Rusin s Reps 9'1 -�Pncne% <br />b)r I P <br />INSTRUCTIONS ON BACK Correct: Incorrect: t <br />■ White Copy: CalRecycle Yellow Copy: Operator Pink <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem / m / m <br />(Required for NOV or EXT) <br />Q Referred / CalRecycle Enforcement <br />® In Compliance - No Violations <br />Phone Number <br />:2:E 62081 <br />