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Waste Tire Su, vey & Inspection Report <br />CalRecycle State of California <br />CalRecycle 181 (Rev. <br />Dept. of Resources Recycling and Recovery (Cal Recycle) S rvey FOiYv P <br />age 1 <br />part A - Survey <br />Business Profile Inspection Details <br />Inspection Report Number <br />I1 - 1210296 <br />BLUE OR BLACK INK PEN <br />TPID - Inspection Type (Fill one) <br />Site Suffix: l 5 Q 93� S b I ® Routine 0 Re -inspection O Referral 0 Observation <br />Local <br />Identifier:✓ <br />Business or Facility Name <br />��� 1 �Sl� <br />Physical Address <br />69,s- Al. 61--- <br />L oc�> f <br />Business Rep <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />Longitude <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair <br />Used Tire Dealer 0 Auto Body <br />0 Service Station 0 Hauler <br />If Referral, choose referral type (Fill one) <br />Q CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br />Inspected By Inspector <br />� 'I - [ o I AIA-716L.L 4 <br />�} a Inspection Date <br />Time In <br />Title <br />1 MVI <br />0 Trucking Fleet <br />0 Car Dealer <br />0 Agriculture <br />5 / a e -r / <br />Time Out <br />U Government U Retreader <br />0 Collection 0 Crumb Rubber <br />0 Shredder 0 Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />. (V AM <br />A <br />3 QPM <br />O <br />Operational Status <br />Tire Type <br />O <br />6 <br />(Fill one only) <br />® Active <br />0 Closed <br />(Fill all that appl <br />® Passenger <br />0 Altered <br />O <br />O <br />0 Inactive <br />0 Truck <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 Planned <br />0 OTR <br />U Government U Retreader <br />0 Collection 0 Crumb Rubber <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 />O <br />O <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />O <br />O <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />O <br />O <br />PRC § 42956 - Registration/Decal in Vehicle <br />O <br />O <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />O <br />O <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Q <br />O <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />O <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 <br />O <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />O <br />O <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />O <br />O <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />O <br />O <br />Other: § <br />Comments <br />0 AM <br />t Z ' O (D ®PM <br />Business Role Storage Type <br />(Fill all that apply) (Fill all that apply) <br />Generator 0 Outdoor <br />0 Hauler 10 Indoor <br />0 End -Use 10 Container <br />Dismantler ( ) Tire Derived Fuel <br />ENFORCEMENT STATUS <br />0 Notice Of Violation O Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />O Referred / CalRecycle Enforcement <br />® In Compliance - No Violations <br />Inspection Form Included: O <br />Comments Included: ® 70 3 d A42'726� 7 <br />_ Business Rep's Signature Phone Number I p 5 nature Phone Number <br />INSTRUCTIONS ON BACK Correct:* Incorrect: 7x*:V:l JEX A L 1 2 3 62081 <br />® White Copy: CalRecycle Yellow Copy: Operator Pin1X_C : L ® 0 <br />