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Waste Tire S,..vey & Inspection Report <br />CalRecycle State of California <br />CalRecycle181(Rev.10/10)Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Part A - Survev <br />Inspection Report Number ■ <br />11 -1226269 <br />BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />Inspection Type (Fill one) <br />TPID - <br />Site Suffix: j 9 0 O <br />1& Routine 0 Re -inspection 0 Referral 0 Observation <br />If Referral, choose referral type (Fill one) <br />0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br />Local � <br />Identifier: - �1 ti- �� WL <br />- - V <br />Business or Facility Name <br />Inspected By Inspector <br />Physical Addressrn <br />3 S . E <br />� V /A r^� r,�ll <br />` 1r�Time <br />Inspection Date <br />t <br />`� <br />In Time Out <br />Business Rep Titleh <br />f% <br />10 AM 7 AM <br />J <br />% 62' 5 QPM D -Z QPM <br />0 <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />- — <br />Tire Count (Whole/PTE) L� S" <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />®Active <br />®Passenger <br />®Generator <br />0 Outdoor <br />0 Closed <br />0 Altered <br />0 Hauler <br />0 Indoor <br />O <br />GPS Latitude <br />0 Inactive <br />0 Truck <br />O <br />Longitude - <br />0 Planned <br />0 OTR <br />0 End -Use <br />0 Container <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br />0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br />Part <br />B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS —1 <br />0 Notice Of Violation 0 Extension <br />V <br />A I <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 />Compliance Deadline <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 />Date m / m / m <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 />(Required for NOV or EX <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 Referred / CalRecycle Enforcement <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 />In Compliance - No Violations <br />0 <br />0 <br />Other: § <br />Comments <br />Inspection Form Included: 0 <br />- , <br />Comments Included: 40 <br />Business Rep's Signature 41XPhone Number I ect Sig re Phone Number <br />INSTRUCTIONS ON BACK Correct: 40 Incorrect: '� <br />EXAM <br />P <br />L <br />1 <br />Z <br />3 <br />62081 <br />■ White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA <br />■ <br />