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Waste Tire Su, vey & Inspection Report <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 - Survev <br />'Inspection Report Number ■ <br />I1 - 1177770 <br />BLUE OR BLACK INK PEN <br />Business Profile <br />V <br />Inspection Details <br />HAULING AND MANIFEST REQUIREMENTS <br />TPID - <br />Site Suffix: 6 6 9 0 © L%j � <br />� � <br />Inspection Type (Fill one) <br />0 Routine 0 Re -inspection 0 Referral 0 Observation <br />If Referral, choose referral type (Fill one) <br />0 Other <br />Local <br />Identifier: sa1(\Ji✓l� C�i/✓ti <br />0 <br />/ <br />0 CHP 0 CalRecycle 0 Complaint <br />0 Educational Visit <br />Business or Facility Name <br />0 <br />Inspected By Inspector <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />i. �o� 5� <br />Physical Address <br />0 <br />�� - <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />1 n t <br />-����/+ <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />Inspection Date �Jr / <br />o/ 1 <br />l <br />�i Q� G�.v a r <br />gsr,20J <br />(-) <br />(-) <br />Other: § <br />Time In <br />Time Out <br />Business Rep Title <br />Px >, <br />y L� O AM <br />{ [ O ® PM <br />O AM <br />o2 0 S 0 PM <br />-` 6 o IQ <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 />0 Active <br />®Closed <br />0 Pas en er <br />0 Alted <br />0 Generator <br />0 Outdoor <br />N/A <br />O <br />GPS Latitude <br />0 Hauler <br />0 Indoor <br />0 Inactive <br />0 Truck <br />Longitude - <br />O <br />0 Planned <br />0 OTR <br />0 End -Use <br />0 Container <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet <br />0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br />® Used Tire Dealer 0 Auto Body 0 Car Dealer <br />0 Collection 0 Crumb Rubber <br />0 Service Station 0 Hauler 0 Agriculture <br />0 Shredder 0 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 />0 <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />(-) <br />(-) <br />Other: § <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Date / m / m <br />(Required for NOV or EXT) <br />0 Referred / CalRecycle Enforcement <br />0 In Compliance - No Violations <br />Co/9M. ,S � 1_ A <br />f1L`Z%t'7L✓v �Yl. ��{l�'M .fY.��/1'1P GN �/L�3 L Al,r, �,r� 1. /7`G'�--> CIY /TlT/r L 4C/)7. S <br />6-K rtr. -hVi` S f- ch -_ A-1- #w_ <br />rlt 1� G�—'INu clircS�L1? �C['�GK Y KC''2'.�- r �()61 <br />OWG,-a_YILi <br />Inspection Form Included: U <br />Comments Included: 0 - <br />Business Rep's Signature _ Phone Number 1 s ecto sgnat <br />i <br />INSTRUCTIONS ON BACK Correct: Incorrect: k4i V E A E <br />0 White Copy: CalRecycle Yellow Copy: Operator Pink Cop L <br />red �'6 Z3 <br />Phone Number <br />62081 <br />© ■ <br />