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0 0 Waste Tire Su. oey & Inspection Reporl ,inspection Report Number <br />CalRecyCle State of California 11-1196742 <br />CalRecycle 181 (Rev. y (Cal Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Part A - Cnrvcaw BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />A <br />TPID - ' 7 r _ © <br />Site Suffix: 7 <br />Inspection Type (Fill one) <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />9 Routine 0 Re -inspection 0 Referral 0 Observation <br />If Referral, choose referral type (Fill one) <br />0 Visit 0 Other <br />Local <br />Identifier: <br />.�Q <br />0 CHP 0 CalRecycle 0 Complaint <br />Educational <br />Business or Facility Name <br />Inspected By Inspector <br />0 <br />Physical Address <br />- <br />)VN v <br />a.v� <br />0 <br />0 <br />S� qS <br />Inspection Date <br />I <br />Z 8 3 <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Time In <br />Time Out <br />Business Rep ,1,�C\S DV �Title� A,� <br />(i 0.1 /"� <br />' Q AM <br />G O <br />� � ,1 Q AM <br />PM <br />,e <br />M Jv <br />0 PM <br />0 <br />a.v `.GL Cyri <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) . <br />4 1 <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />I* Active <br />0 Closed <br />0 Passenger <br />0 Altered <br />0 Generator <br />Q Hauler <br />0 Outdoor <br />•Indoor <br />O <br />GPS Latitude <br />O <br />0 Inactive <br />• Truck <br />Longitude - <br />0 Planned <br />• OTR <br />0 End -Use <br />0 Container <br />Business Type (Fill all that apply) <br />fm <br />0 New Tire Dealer 0 Auto Repair 4& Trucking Fleet 0 Government 0 Retreader Dismantler 0 Tire Derived Fuel <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection <br />0 Crumb Rubber <br />0 Service Station 0 Hauler 0 Agriculture 0 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 />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 />0 <br />0 <br />Other: § <br />Comments <br />ZC4t- <br />Inspection Form Included: <br />Comments <br />E <br />INSTRU <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Datem / m / m <br />(Required for NOV or EX7) <br />0 Referred / CalRecycle Enforcement <br />&In Compliance - No Violations <br />u'ii s R'ep's Signature Phone Number Inspector's Signature Phone Number <br />BACK Correct: 0 Incorrect: X74Rq1EE1XjAjMjPjLjEj 1112 H3 62081 <br />White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA ® 0 <br />Lu <br />W <br />