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Waste Tire SSey & Inspection Reporpinspection Report Number <br />CalRec cle State of California — <br />Y CalRecycle 181 (Rev. 10110) Survey Form -Page 1 I1 1255761 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />part A - SilrvPv BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPID -Q� , <br />Site Suffix: y Z C6 I -7 <br />Inspection Type (Fill one) <br />v <br />• Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />O CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br />Local <br />Identifier: 15Ck b YN, VAY <br />Business or Facility Name <br />Inspected By Inspector <br />Qt7M S 52c� c -e5 <br />Physical Address <br />_ l d i M� TT v <br />c <br />S,r C11\_ b <br />Inspection Date <br />Time In Time Out <br />Business Rep Title <br />0 AM 0 AM <br />Z • D � ' � O <br />^ A <br />QPM *PM <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 />O Active <br />O Passenger <br />Generator <br />0 Outdoor <br />`A- <br />D <br />GPS Latitude <br />0 Closed <br />O Altered <br />0 Hauler <br />J"l <br />0 Indoor <br />Q Inactive <br />0 Truck <br />0 <br />Longitude - <br />0 Planned <br />O OTR <br />O End -Use <br />0 Container <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <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 />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 />O <br />Q <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 />Compliance Deadline <br />PRC § 42956 - Registration/Decal in Vehicle <br />O <br />O <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date m <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />O <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 />0 <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />O <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 Referred / CalRecycle Enforcement <br />O <br />Q <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 />In Compliance - No Violations <br />O <br />Q <br />Other: § <br />Comments <br />(7_ 4 �OLCOC �•�� ,_�S 2C V\av_ <br />�-C211$_� '�1 <br />a <br />�a v�o�r�,��w or lea,S cs� Cav�cer� <br />Inspection Form Included: Q <br />I ) 051 <br />Comments Included. 'n <br />Hess ep s Phone Number Inspector's Signature Phone Number <br />INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P L E 1112 3 62081 <br />White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA <br />