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Waste Tire Sur Bey & Inspection Report <br />CalRecycle <br />state of California <br />CalRecycle 181 (Rev. (Cal Survey Fora - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />,art A - Survey <br />Business Profile Inspection Details <br />Site Suffix: loa <br />Local <br />!® <br />Identifier: Sct o v 0"L 1'r) C-0 a t 1 <br />Business or Facility Name L <br />Physical Address <br />inspection Report Number ■ <br />I1 -1177965 <br />BLUE OR BLACK INK PEN <br />Inspection Type (Fill one) <br />® Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Inspected By Inspector <br />3 9 - <br />Inspection Date / 1 <br />Time In Time Out <br />Business Rep <br />Title <br />A I <br />I <br />O AM <br />� <br />� <br />O AM <br />� � <br />/ <br />Din(1j S (1!1 � rl � D n <br />b L,0ries <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />� '5 <br />®PM <br />PRC § 42956 - Registration/Decal in Vehicle <br />®PM <br />v -- <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) <br />Q <br />Q <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) (Fill all that apply) <br />� <br />� <br />Q <br />0 Active <br />Q Closed <br />® Passenger <br />Q Altered <br />® Generator <br />Q Hauler <br />® Outdoor <br />Q Indoor <br />O <br />GPS Latitude <br />L Q <br />Other: § <br />Comments Y—) . _ . tt w .. t _ 1. 1 ., n_ . U _ _ j <br />Q Inactive <br />Q Truck <br />Longitude — <br />0 <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />New Tire Dealer Q Auto Repair <br />Q Trucking Fleet <br />Q Government Q Retreader Q Dismantler <br />Q Tire Derived Fuel <br />e Used Tire Dealer Q Auto Body <br />Q Car Dealer <br />Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler <br />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 I <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 />L Q <br />Other: § <br />Comments Y—) . _ . tt w .. t _ 1. 1 ., n_ . U _ _ j <br />l� <br />Inspection Form Included: Q rJ <br />Comments Included: <br />Business Rep's Signat <br />■ INSTRUCTIONS ON BACK Correct: <br />White Copy: CalRecycle <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date /m/m <br />(Required for NOV or EX7) <br />Q Referred / CalRecycle Enforcement <br />® In Compliance - No Violations <br />a <br />V� �t1c�s 0 (Oso r� <br />Phone Number <br />Phone Number <br />62081 <br />Incorrect: E X A M L 1 2 3 <br />Yellow Copy: Operator Pink Copy ® ■ <br />LU <br />LU <br />