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Waste Tire Su. vey & Inspection Repor <br />CalRecycle State of California <br />CalRecycle 181 (Rev. 10/10) <br />(Cal Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />r%__4 A c.....,,.. <br />Inspection Report Number ■ <br />I1 - 1245213 <br />BLUE OR BLACK INK PEN <br />Business Profile <br />V <br />Inspection Details <br />HAULING AND MANIFEST REQUIREMENTS <br />TPISite - /` _ <br />Site Suffix: 7 <br />O <br />InspectionRoui Type (Fill one) p Q Q <br />Routine Re -inspection Referral 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: C> Y\ � <br />III�JJJ���""" <br />Business or Facility Name <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Inspected By Inspector <br />Q <br />Nvmw <br />Physical Address <br />Q <br />3 q- � a 1 <br />M A S <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Q <br />Q <br />`— % <br />C� <br />S <br />�" <br />Inspection Date 0 7 <br />v <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />Time In <br />Time Out <br />Business Rep Title <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />S O AM <br />O AM <br />� <br />r ` <br />a <br />0 PM <br />V QPM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE)(Fill <br />1 <br />one only) <br />• Active <br />Q Closed <br />(Fill all that apply) <br />Q Passenger <br />Q Altered <br />(Fill all that apply) <br />0 Generator <br />Q Hauler <br />(Fill all that apply) <br />`Outdoor <br />Q Indoor <br />O <br />GPS Latitude <br />O <br />Q Inactive <br />. Truck <br />Longitude - <br />Q Planned <br />Q OTR <br />Q End -Use <br />0 Container Z <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair 0 Trucking Fleet <br />Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer Q Auto Body Q Car Dealer <br />Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler Q Agriculture <br />Q Shredder 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 />Q <br />Q <br />Other: § <br />Comments V--,.. , 'e— t'`r SV*- , \ C-,e <br />I <br />Inspection Form Included: <br />Comments Included: <br />M-- hsb--_� <br />Phone Number <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EX7) <br />Q Referred / CalRecycle Enforcement <br />In Compliance - No Violations <br />�32� <br />� <br />Phone Number <br />62081 <br />INSTRUCTIONS ON BACK Correct:0 Incorrect: g E X A M O�E 2 3■ White Copy: CalRecycle Yellow Copy: Operator Pink Copy: © ■ <br />