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Waste Tire S&ey & Inspection Repor, , Inspection Report Number <br />State of California <br />CalRecycle 11 - 1244958 <br />CalRecycle 181 (Rev. (Cal Survey Form -Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Sart A - Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID - I Q C <br />Site Suffix: Ll 1p p t <br />Local 1 <br />S <br />Identifier: All 0� Lt t �1 l LAP <br />- b <br />Business or Facility Name <br />Physical Address <br />�10\\ N_ b ro" wc.� A"Vc <br />1 Inspection Type (Fill one) <br />J ® 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 />mac) &-ko C q Szos <br />Business Rep Title <br />Tire Count (Whole/PTE) <br />O <br />GPS Latitude <br />O <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 />Q Trucking Fleet <br />Q Car Dealer <br />Q Agriculture <br />Inspected By <br />3q - <br />Inspection Date <br />Time In <br />12:3 <br />Operational Status <br />(Fill one only) <br />Q Active <br />® Closed <br />Q Inactive <br />Q Planned <br />Government <br />Q Collection <br />Q Shredder <br />Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q Crumb Rubber <br />Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />Inspector <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />Q <br />7 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Time Out <br />Q AM <br />t/ PM <br />L1 Q AM <br />I m PM <br />Tire Type <br />Business Role Storage Type <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />Q Passen er <br />Q Ggnerator <br />1 <br />Q Outdoor <br />1 Y I <br />OA <br />I�'J <br />PI <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />Q Hauler <br />Q Ind"obr <br />Q Truck <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q OTR <br />Q End -Use <br />Q Container <br />Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q Crumb Rubber <br />Q 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 />0_L0 <br />Other: § <br />Comments d?Vmlltlel Wk4L- 0,��iS <br />ENFORCEMENT! <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 />0 In Compliance - No Violations <br />y7 <br />LAS (10}x'• <br />ND Olzt ► mss_ Of ok1" 04 (.v -)c c 10 . <br />'10 (bscz GCI 4'� $t_" I f �z � <br />Inspection Form Included: 0 <br />• 2aq - zoo qct -3» <br />Comments Included: O <br />Business Rep's ignature Phone Number Insp tor's Signature Phone Number <br />INSTRUCTIONS ON BACK Correct:O Incorrect: X "�-' EXAMPLE 11273 62081 <br />White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA <br />