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Waste Tire Su. Bey & Inspection Report <br />CalRecycle State of California <br />CalRecycle 181(Rev.(Cal Survey Form -Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Part A - Survev <br />,!,ispection Report Number <br />I1 -1210349 <br />BLUE OR BLACK INK PEN <br />Business Profile <br />V <br />A <br />Inspection Details <br />0 <br />0 <br />TPID - 1 <br />Site Suffix: "1 <br />© - <br />® <br />Inspection Type (Fill one) <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />e 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: aq V;� VY�` <br />11 <br />Business or Facility Name <br />0 <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Inspected By Inspector <br />0 <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />TCL00- P �c� ;� <br />Physical Addrbss T <br />0 <br />�j � - <br />�`� T\13 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />o� <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />M <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />n <br />n <br />Other: § <br />GS2oS <br />Inspection Date 6 / <br />d S / <br />1 3 <br />Sk00r <br />CN <br />Time In <br />Time Out <br />Business Re <br />j(?v�n1Y1�L k <br />Title <br />(�c.►hCtS <br />4jbvn <br />0 AM <br />C) <br />0'M <br />O <br />\ <br />® PM <br />0 PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) <br />0(Fill <br />one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />0 Active <br />0 Passenger <br />0 Generator <br />0 Outdoor <br />0 Closed <br />0 Altered <br />NIA <br />/WA <br />O <br />GPS Latitude <br />tj/A <br />0 Hauler <br />0 Indoor <br />Q Inactive <br />Q Truck <br />Longitude - <br />0 <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 <br />0 Trucking Fleet <br />0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br />0 Used Tire Dealer 0 Auto Body <br />0 Car Dealer <br />0 Collection 0 Crumb Rubber <br />0 Service Station 0 Hauler <br />0 Agriculture <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 />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 />n <br />n <br />Other: § <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Datem/m/� <br />(Required for NOV or EXT) <br />0 Referred / CalRecycle Enforcement <br />4b In Compliance - No Violations <br />CommentsL <br />�v.sp ,n cor a on��1 <br />ova �S a�a.4_ow. <br />�o woos V�o�c� . MO � zb of . <br />CW <br />%oke_S : ' Soak, P% ek kN �c : �no5 CXoS 2c3� () �cT *A.sL �sr c��Lle t ,J 1�ta S Q <br />0V31A2(" �Z2coylnv+�e,n��j•S_'��Z� doe C�oSe <br />Inspection Form Included: ZCJq �b <br />a- 3� $ 1 <br />Comments Included: wt-pi-40—y <br />Business p's Signature Phone Number Insp ctor's Signature Phone Number <br />�,( <br />INSTRUCTIONS ON BACK Correct: Incorrect: X g E X A M P L E 1112 3 62081 <br />White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA ® 0 <br />