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Waste Tire S !ey & Inspection Repor Inspection Report Number ■ <br />cle State of California <br />CalRecycle — <br />Y CalRecycle 181 (Rev. 10/10) Survey Form -Page 1 11 1196620 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />111--& n c....,.,., BLUE OR BLACK INK PEN <br />Business Profile <br />V <br />A <br />Inspection Details <br />TPID - <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Inspection Type (Fill one) <br />Site Suffix: l -7 � <br />-5- <br />d f! <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 />Local` <br />Identifier: `kv1 <br />Business or Facility Name <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Inspected By Inspector <br />I% <br />14 CCR § 18459.1 -Tire Program ID Number from CalRecycle <br />Q <br />Q <br />Physical Address <br />Q <br />Q <br />;3 - C� l 1"8 Le4 <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 />Inspection Date11 - / ® <br />vlc' L�CCcam_ <br />o <br />vsS <br />�J33 0Time <br />Other: § <br />In Time Out <br />Business Rep <br />Title <br />O AM O AM <br />L • pZ O PM 'J S ® PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE)(Fill <br />t 5 <br />one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />® Active <br />Q Closed <br />O' Passenger <br />Q Altered <br />0 Generator <br />Q Hauler <br />Q Outdoor <br />®Indoor <br />�P� Latitude <br />o <br />Q Inactive <br />Q Truck <br />Longitude - <br />O <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair <br />Q Trucking Fleet <br />Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer Q Auto Body <br />Q Car Dealer <br />Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler <br />Q Agriculture <br />Q Shredder ® 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 />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 />Q <br />Q <br />Other: § <br />Comments <br />l! <br />Inspection Form Included: Q <br />Comments Included: Z` <br />Business Rep's Signature Phone Number <br />INSTRUCTIONS ON BACK Correct: Incorrect: <br />White Copy: CalRecycle Yellow Copy: Operator <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date m / Ffl / m <br />(Required for NOV or EXT) <br />Q Referred / CalRecycle Enforcement <br />® In Compliance - No Violations <br />AZ( <br />N <br />0 <br />Lu <br />Lu <br />isp •tor's S'&2 re Phone Number <br />KIAIMIPIL4EI 1112 3 62081 <br />Pink Copy: LEA ® ■ <br />